Active NPI
Brooke Elizabeth Wietharn, MD
- Surgery Physician
- Grand Rapids, MI
National Provider Identifier
1689419087
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgery Physician
- License
- 2024025232
- Practice address
- 200 Jefferson Ave SE
Grand Rapids, MI 49503-4502 - Phone
- (616) 685-6922
- Fax
- (616) 685-5192
- NPI assigned
- Jun 27, 2024
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgery Physician | 208600000X | 2024025232 | MO | Primary |
Addresses
Primary practice location
200 Jefferson Ave SE
Grand Rapids, MI 49503-4502
Mailing address
1 Hospital Dr
Columbia, MO 65212-1000
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MO
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20240911004312 | MO | Order and Referring Only - General Surgery | 3577003920 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2024025232 | MO | MD | Surgery Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1719446400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1788307200000",
"number": "1689419087",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1 HOSPITAL DR",
"city": "COLUMBIA",
"state": "MO",
"postal_code": "652121000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "200 JEFFERSON AVE SE",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "495034502",
"telephone_number": "616-685-6922",
"fax_number": "616-685-5192"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIETHARN",
"first_name": "BROOKE",
"middle_name": "ELIZABETH",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2024-06-27",
"last_updated": "2026-09-02",
"certification_date": "2026-09-02",
"status": "A"
},
"taxonomies": [
{
"code": "208600000X",
"taxonomy_group": "",
"desc": "Surgery",
"state": "MO",
"license": "2024025232",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Grand Rapids, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 2, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.