Basic Information
| Provider Information | |||||||||
| NPI: | 1154633857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIEDOWER | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7714 POPLAR AVE STE 200 | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381383941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
| FaxNumber: | 9019226722 | ||||||||
| Practice Location | |||||||||
| Address1: | 7945 WOLF RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2010 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 3015 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 24301 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 08484348 | 05 | MS | MEDICAID | Q022586 | 05 | TN | MEDICAID |