Provider Demographics
NPI:1760848568
Name:WEAVER MEDICAL GROUP
Entity Type:Organization
Organization Name:WEAVER MEDICAL GROUP
Other - Org Name:WEAVER MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:865-777-6888
Mailing Address - Street 1:6709 KINGSTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-4830
Mailing Address - Country:US
Mailing Address - Phone:865-777-6888
Mailing Address - Fax:888-606-4866
Practice Address - Street 1:6709 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4830
Practice Address - Country:US
Practice Address - Phone:865-777-6888
Practice Address - Fax:888-606-4866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001044332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1523744Medicaid
TN6509330001Medicare UPIN