Provider Demographics
NPI:1619392909
Name:WIEMHOLT, EDWARD B III (DO)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:B
Last Name:WIEMHOLT
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 CAMBRIDGE ST # MS 1020
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8501
Mailing Address - Country:US
Mailing Address - Phone:913-588-6005
Mailing Address - Fax:
Practice Address - Street 1:4000 CAMBRIDGE ST # MS 1020
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-8501
Practice Address - Country:US
Practice Address - Phone:913-588-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204328207R00000X
MO2020040036207R00000X, 208M00000X
390200000X
KS05-49353208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200095382Medicaid