1154419802 NPI number — DOCTORS WEAVER & WEAVER P C

Table of content: (NPI 1154419802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154419802 NPI number — DOCTORS WEAVER & WEAVER P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTORS WEAVER & WEAVER P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154419802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5304 INDIAN GRAVE RD SW
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-9108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-772-7107
Provider Business Mailing Address Fax Number:
540-772-7858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5304 INDIAN GRAVE RD SW
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-9108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-772-7107
Provider Business Practice Location Address Fax Number:
540-772-7858
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SEBESTIN
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
540-772-7107

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  0101033189 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 006196705 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: C12923 . This is a "RAILROAD MEDICARE LEGACY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 006104321 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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