Provider Demographics
NPI:1740256973
Name:WEAVERLING, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:WEAVERLING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ROUTE 56
Mailing Address - Street 2:BOX 123
Mailing Address - City:FISHERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2040 QUAKER VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:FISHERTOWN
Practice Address - State:PA
Practice Address - Zip Code:15539
Practice Address - Country:US
Practice Address - Phone:814-839-4152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029361E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB34288Medicare UPIN
PA045464PEEMedicare ID - Type Unspecified