Provider Demographics
NPI:1063583763
Name:WEATHERRED, TED W (MD)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:W
Last Name:WEATHERRED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28068
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37424-8068
Mailing Address - Country:US
Mailing Address - Phone:877-899-1033
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:ROOM 2144
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-3873
Practice Address - Fax:706-721-7763
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034979207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA550789920OtherTRICARE
GA339267OtherWELLCARE CMO
GA480929OtherBCBS
GA050031131OtherRRMEDICARE
GA000542165BMedicaid
GA000542165CMedicaid
SCG34979Medicaid
GA05BDJLBMedicare ID - Type Unspecified
SCG34979Medicaid