Provider Demographics
NPI:1255659272
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:ACCOUNTS PAYABLE
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 1:1099 BELT LINE RD
Practice Address - Street 2:STE A
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4380
Practice Address - Country:US
Practice Address - Phone:618-344-4527
Practice Address - Fax:618-344-7380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RONALD WEEMS JR. P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-14
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190270831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty