Provider Demographics
NPI:1033187711
Name:MOUNTAIN INTERNAL MEDICINE
Entity Type:Organization
Organization Name:MOUNTAIN INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RHETT
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-754-8518
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-0880
Mailing Address - Country:US
Mailing Address - Phone:706-754-8518
Mailing Address - Fax:706-754-6238
Practice Address - Street 1:835 AUSTIN DR
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4513
Practice Address - Country:US
Practice Address - Phone:706-754-8518
Practice Address - Fax:706-754-6238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029819207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000509308AMedicaid
GA355686OtherWELLCARE
GA355686OtherWELLCARE