Provider Demographics
NPI:1033195490
Name:WEATHERS, EVERETTE ARDEN (MD)
Entity Type:Individual
Prefix:
First Name:EVERETTE
Middle Name:ARDEN
Last Name:WEATHERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-536-2555
Mailing Address - Fax:803-536-0998
Practice Address - Street 1:1175 COOK RD
Practice Address - Street 2:SUITE 320
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8201
Practice Address - Country:US
Practice Address - Phone:803-536-2555
Practice Address - Fax:803-536-0998
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5244208600000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576008010-012OtherBCBS
SC32409OtherMEDCOST
SC9204593OtherCIGNA
SC622230OtherFIRST CHOICE
SC052445Medicaid
SC9645030OtherGHI
SC576008010-012OtherBCBS
SC9204593OtherCIGNA
SCB91999Medicare UPIN