1619910627 NPI number — DR. BRADLEY KENT WEISNER M.D.

Table of content: DR. BRADLEY KENT WEISNER M.D. (NPI 1619910627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619910627 NPI number — DR. BRADLEY KENT WEISNER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEISNER
Provider First Name:
BRADLEY
Provider Middle Name:
KENT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1619910627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 36488
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28236-6488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-248-3400
Provider Business Mailing Address Fax Number:
704-337-8387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 MATTHEWS TOWNSHIP PKWY
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
MATTHEWS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28105-2387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-841-8877
Provider Business Practice Location Address Fax Number:
704-841-8188
Provider Enumeration Date:
06/14/2006

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: 208800000X , with the licence number:  9400668 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 23482 . This is a "PARTNERS PROVIDER#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 340016171 . This is a "RAILROAD MCRE PROV#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 86336 . This is a "BCBS NC INDI PROV#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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