Provider Demographics
NPI:1710214036
Name:GERALD E WEAVER MD PC
Entity Type:Organization
Organization Name:GERALD E WEAVER MD PC
Other - Org Name:WORLAND SURGERY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-347-2405
Mailing Address - Street 1:1511 CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-4122
Mailing Address - Country:US
Mailing Address - Phone:307-347-2405
Mailing Address - Fax:307-347-3166
Practice Address - Street 1:1511 CHARLES AVE
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-4122
Practice Address - Country:US
Practice Address - Phone:307-347-2405
Practice Address - Fax:307-347-3166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5731A302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114723400Medicaid
WY114723400Medicaid