1013912104 NPI number — COREY WEIDMAN PA-C

Table of content: COREY WEIDMAN PA-C (NPI 1013912104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013912104 NPI number — COREY WEIDMAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEIDMAN
Provider First Name:
COREY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1013912104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 457
Provider Second Line Business Mailing Address:
5 E ALVON ROAD, SUITE 7
Provider Business Mailing Address City Name:
WHITE SULPHUR SPRINGS
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24986-2373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-536-5030
Provider Business Mailing Address Fax Number:
304-536-5051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
JACKSON RIVER ORTHOPEDICS
Provider Second Line Business Practice Location Address:
1 ARH LANE, STE 102
Provider Business Practice Location Address City Name:
LOW MOOR
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-862-6777
Provider Business Practice Location Address Fax Number:
540-863-9167
Provider Enumeration Date:
06/16/2005

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: 363A00000X , with the licence number:  0110840643 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 54183971800 . This is a "WV WORKERS COMPENSATION" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 541839718045 . This is a "BS MOUNTAIN STATE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541839718 . This is a "C&O" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001717977 . This is a "BSMT" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 200026 . This is a "LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 258083 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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