Provider Demographics
NPI:1124121298
Name:MARK T. WEAVER, M.D., P.C.
Entity type:Organization
Organization Name:MARK T. WEAVER, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-856-6939
Mailing Address - Street 1:125 W GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:HARTWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30643-1848
Mailing Address - Country:US
Mailing Address - Phone:706-856-6939
Mailing Address - Fax:706-836-6199
Practice Address - Street 1:125 W GIBSON ST
Practice Address - Street 2:
Practice Address - City:HARTWELL
Practice Address - State:GA
Practice Address - Zip Code:30643-1848
Practice Address - Country:US
Practice Address - Phone:706-856-6939
Practice Address - Fax:706-836-6199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052851207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH86622Medicare UPIN