Provider Demographics
NPI:1821007816
Name:JOHN WEISSE PROFESSIONAL ASSOC
Entity Type:Organization
Organization Name:JOHN WEISSE PROFESSIONAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEISSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD PH D
Authorized Official - Phone:479-452-4400
Mailing Address - Street 1:5622 ROGERS AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903
Mailing Address - Country:US
Mailing Address - Phone:479-452-4400
Mailing Address - Fax:479-452-4406
Practice Address - Street 1:5622 ROGERS AVENUE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-452-4400
Practice Address - Fax:479-452-4406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
57351Medicare ID - Type Unspecified