Provider Demographics
NPI:1811979263
Name:WEASE, KATHRYN D (MD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:D
Last Name:WEASE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:DAWNELL
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3601 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6712
Mailing Address - Country:US
Mailing Address - Phone:248-691-8646
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-691-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063278208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G51624Medicare UPIN
OM88530Medicare ID - Type Unspecified