Glenn W Weidenbacher, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

48083 Issued in MN

Practice address

16830 198TH Ave NW
Big Lake Clinic
Big Lake, MN 55309

Phone

(763) 263-7300

Fax

(763) 263-7334

NPI assigned

Dec 22, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Interoperability endpoints

• Direct secure messaging: gweidenbacher3347@direct.northmemorial.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Centracare Clinic

  dba CentraCare - Big Lake Clinic

  • Multi-Specialty Clinic/Center
  • Big Lake, MN
  • NPI 1013104348
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1135209600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1205107200000",
    "number": "1801873674",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16830 198TH AVE NW",
            "address_2": "BIG LAKE CLINIC",
            "city": "BIG LAKE",
            "state": "MN",
            "postal_code": "55309",
            "telephone_number": "763-263-7300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16830 198TH AVE NW",
            "address_2": "BIG LAKE CLINIC",
            "city": "BIG LAKE",
            "state": "MN",
            "postal_code": "55309",
            "telephone_number": "763-263-7300",
            "fax_number": "763-263-7334"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WEIDENBACHER",
        "first_name": "GLENN",
        "middle_name": "W",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-12-22",
        "last_updated": "2008-03-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "MN",
            "license": "48083",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Erin Viegut, PT, DPT
• Mariane Lyn Walin, PT, DPT, CIMT
• Jennica Wanha, MA
• Robert D Wark, MA LMFT
• Stephanie Ruth Warwas, LICSW
• Sara Jean Winkelman, M.S. CCC-SLP
• Kimberly Ann Wojack, R.D.H.
• Rawan Yaghi, DDS

• Pediatrics Physician in Big Lake, MN
• Providers in Big Lake, MN by specialty
• Pediatrics Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 10, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.