Provider Demographics
NPI:1194133884
Name:BOULEVARD FAMILY PRACTICE
Entity type:Organization
Organization Name:BOULEVARD FAMILY PRACTICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:MBBS
Authorized Official - Phone:706-850-6134
Mailing Address - Street 1:855 W BROAD ST STE A
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2511
Mailing Address - Country:US
Mailing Address - Phone:706-850-6134
Mailing Address - Fax:706-850-6318
Practice Address - Street 1:855 W BROAD ST STE A
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2511
Practice Address - Country:US
Practice Address - Phone:706-850-6134
Practice Address - Fax:706-850-6318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-26
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
AZAZ47265261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty