1316914500 NPI number — DR. MARY WEATHERINGTON

Table of content: DR. MARY WEATHERINGTON (NPI 1316914500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316914500 NPI number — DR. MARY WEATHERINGTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEATHERINGTON
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1316914500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5428 POLO WOODS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45014-4778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-829-9731
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 STEFFEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN HEIGHTS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45215-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-588-3623
Provider Business Practice Location Address Fax Number:
513-588-3649
Provider Enumeration Date:
03/07/2006

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: 207R00000X , with the licence number:  35-06-6966-W , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0160089 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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