Provider Demographics
NPI:1295802619
Name:WEBER MEDICAL SERVICES PC
Entity type:Organization
Organization Name:WEBER MEDICAL SERVICES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:PA C
Authorized Official - Phone:605-685-1450
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:SD
Mailing Address - Zip Code:57551-0370
Mailing Address - Country:US
Mailing Address - Phone:605-685-1450
Mailing Address - Fax:605-685-1453
Practice Address - Street 1:109 PUGH STREET
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:SD
Practice Address - Zip Code:57551-0370
Practice Address - Country:US
Practice Address - Phone:605-685-1450
Practice Address - Fax:605-685-1453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5300880Medicaid
SD4994699OtherWELLMARK
SD433889Medicare ID - Type UnspecifiedMEDICARE