Provider Demographics
NPI:1104098144
Name:RONALD WEEMS JR. P.C.
Entity type:Organization
Organization Name:RONALD WEEMS JR. P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-288-6201
Mailing Address - Street 1:26 GINGER CREEK PKWY
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-3502
Mailing Address - Country:US
Mailing Address - Phone:618-288-6201
Mailing Address - Fax:618-288-6452
Practice Address - Street 1:3429 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3709
Practice Address - Country:US
Practice Address - Phone:618-452-2006
Practice Address - Fax:618-452-3077
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RONALD WEEMS JR. P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-31
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025159122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty