MEDICARE: MARC W. WEISE, M.D., INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	5684480001	CA
2	207X00000X	Orthopaedic Surgery Physician	2852009	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	611373100	OTHER		USDEPT OF LABOR

General Provider Information

NPI Number	:	1174650279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARC W. WEISE, M.D., INC.

Provider Business Mailing Address
First Line	:	2 JAMES WAY
Second Line	:	SUITE 115
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-4973
Country	:	US
Telephone Number	:	805-773-2650
Fax Number	:	805-773-2655

Provider Business Practice Location Address
First Line	:	2 JAMES WAY
Second Line	:	SUITE 115
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-4973
Country	:	US
Telephone Number	:	805-773-2650
Fax Number	:	805-773-2655

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARC W WEISE
Credential	:	MD
Telephone Number	:	805-773-2650

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	05/15/2012

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