Provider Demographics
NPI:1851573778
Name:JERE H. WEAVER
Entity Type:Organization
Organization Name:JERE H. WEAVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-351-1874
Mailing Address - Street 1:722 BANK ST NE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-1610
Mailing Address - Country:US
Mailing Address - Phone:256-351-1874
Mailing Address - Fax:256-351-1876
Practice Address - Street 1:722 BANK ST NE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-1610
Practice Address - Country:US
Practice Address - Phone:256-351-1874
Practice Address - Fax:256-351-1876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11631207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009912888Medicaid
AL515-97711OtherBLUE CROSS BLUE SHIELD
AL51025264OtherBLUE CROSS PROVIDER NUMBE
AL=========-002OtherAETNA
AL51025264OtherBLUE CROSS PROVIDER NUMBE
ALE465Medicare PIN
ALC72892Medicare UPIN