Provider Demographics
NPI:1811097108
Name:WESTON, LAWRENCE TYE (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:TYE
Last Name:WESTON
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:712 GROVE ROAD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4211
Practice Address - Country:US
Practice Address - Phone:864-522-1400
Practice Address - Fax:864-522-1429
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22651207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00900031OtherRR MEDICARE
SCT66318Medicaid
SCP00900031OtherRR MEDICARE
SCAA60547951Medicare PIN