Provider Demographics
NPI:1508392267
Name:BOULEVARD FAMILY PRACTICE
Entity Type:Organization
Organization Name:BOULEVARD FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:MBBS
Authorized Official - Phone:706-850-6134
Mailing Address - Street 1:1010 PRINCE AVE STE 184
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5815
Mailing Address - Country:US
Mailing Address - Phone:706-850-6134
Mailing Address - Fax:
Practice Address - Street 1:1010 PRINCE AVE STE 184
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5815
Practice Address - Country:US
Practice Address - Phone:706-850-6134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72846207Q00000X
GA72811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty