Provider Demographics
NPI:1659447654
Name:LISA A WEAVER
Entity Type:Organization
Organization Name:LISA A WEAVER
Other - Org Name:EASTSIDE FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:931-424-1330
Mailing Address - Street 1:104 IVY LN
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-4550
Mailing Address - Country:US
Mailing Address - Phone:931-424-1330
Mailing Address - Fax:931-424-0019
Practice Address - Street 1:104 IVY LN
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4550
Practice Address - Country:US
Practice Address - Phone:931-424-1330
Practice Address - Fax:931-424-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3710887Medicaid
TN3710887Medicare PIN
TN3710887Medicaid