Provider Demographics
NPI:1376071449
Name:WEICK, JACK WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WILLIAM
Last Name:WEICK
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 1:285 E STATE ST STE 500
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4359
Mailing Address - Country:US
Mailing Address - Phone:614-566-7777
Mailing Address - Fax:614-566-8880
Practice Address - Street 1:285 E STATE ST STE 500
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4359
Practice Address - Country:US
Practice Address - Phone:614-566-7777
Practice Address - Fax:614-566-8880
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301112424207X00000X
TX390200000X
OH35.148393207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program