Basic Information
| Provider Information | |||||||||
| NPI: | 1417063108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIEGERS | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | GEORGE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1235 E CHEROKEE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178202000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1235 E CHEROKEE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178202000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 007267 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2000164030 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204589006 | 05 | MO | MEDICAID |