Provider Demographics
NPI:1831482264
Name:WEAVER NEUROSURGICAL SPINE, PC
Entity Type:Organization
Organization Name:WEAVER NEUROSURGICAL SPINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:NEWMAN
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:540-772-7107
Mailing Address - Street 1:5304 INDIAN GRAVE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-9100
Mailing Address - Country:US
Mailing Address - Phone:540-772-7107
Mailing Address - Fax:540-772-7858
Practice Address - Street 1:5304 INDIAN GRAVE RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-9100
Practice Address - Country:US
Practice Address - Phone:540-772-7107
Practice Address - Fax:540-772-7858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033189207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6196705Medicaid
140000067Medicare PIN
VA6196705Medicaid