1417258856 NPI number — MR. BROCK ANDREW WEAVER DPT

Table of content: MR. BROCK ANDREW WEAVER DPT (NPI 1417258856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417258856 NPI number — MR. BROCK ANDREW WEAVER DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEAVER
Provider First Name:
BROCK
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

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:
1417258856
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3960 ROUTE 30
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
LATROBE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15650-5518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-532-3422
Provider Business Mailing Address Fax Number:
724-532-3424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3960 ROUTE 30 STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATROBE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15650-5518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-532-3422
Provider Business Practice Location Address Fax Number:
724-532-3424
Provider Enumeration Date:
11/16/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT020931 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: DAPT002756 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1007683490007 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1025442830002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 826724 . This is a "HIGHMARK BC/BS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".