1447450143 NPI number — THELSA THOMAS WEICKERT MD

Table of content: THELSA THOMAS WEICKERT MD (NPI 1447450143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447450143 NPI number — THELSA THOMAS WEICKERT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEICKERT
Provider First Name:
THELSA
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PULIKKOTIL
Provider Other First Name:
THELSA
Provider Other Middle Name:
THOMAS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1447450143
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:
160 DENTAL CIRCLE
Provider Second Line Business Mailing Address:
CAMPUS BOX 7075
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-966-5201
Provider Business Mailing Address Fax Number:
919-966-1743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 DENTAL CIRCLE
Provider Second Line Business Practice Location Address:
CAMPUS BOX 7075
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-966-5201
Provider Business Practice Location Address Fax Number:
919-966-1743
Provider Enumeration Date:
07/20/2007

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:  45875 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 068543 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 55186017 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com