Provider Demographics
NPI:1255504924
Name:PEACHTREE ENT & FACIAL PLASTICS PA
Entity Type:Organization
Organization Name:PEACHTREE ENT & FACIAL PLASTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:WEISENBURGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:828-837-3223
Mailing Address - Street 1:145 MEDICAL PARK LANE
Mailing Address - Street 2:SUITE J
Mailing Address - City:MURPHY
Mailing Address - State:NC
Mailing Address - Zip Code:28906-6663
Mailing Address - Country:US
Mailing Address - Phone:828-837-3223
Mailing Address - Fax:828-837-7706
Practice Address - Street 1:145 MEDICAL PARK LANE
Practice Address - Street 2:SUITE J
Practice Address - City:MURPHY
Practice Address - State:NC
Practice Address - Zip Code:28906-6663
Practice Address - Country:US
Practice Address - Phone:828-837-3223
Practice Address - Fax:828-837-7706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-01919207Y00000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908853Medicaid
NC5908853Medicaid