Provider Demographics
NPI:1619969631
Name:WEISS, GALEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:GALEN
Middle Name:A
Last Name:WEISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1698 OLD LEBANON RD
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9662
Mailing Address - Country:US
Mailing Address - Phone:270-465-0632
Mailing Address - Fax:270-789-6119
Practice Address - Street 1:1698 OLD LEBANON RD
Practice Address - Street 2:SUITE 3A
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9662
Practice Address - Country:US
Practice Address - Phone:270-465-0632
Practice Address - Fax:270-789-6119
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036117981174400000X
KY28849207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64288491Medicaid
SC276980Medicare ID - Type Unspecified
SCG703501548Medicare ID - Type Unspecified
KY64288491Medicaid
SCG70350Medicare UPIN