MEDICARE: DR. JOHN BENNETT WEAVER II MD

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	207R00000X	Internal Medicine Physician	00013008	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689638058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN BENNETT WEAVER II MD

Provider Business Mailing Address
First Line	:	189 GOURGE RD
Second Line	:
City	:	HENAGAR
State	:	AL
Zip	:	35978-5119
Country	:	US
Telephone Number	:	205-300-2710
Fax Number	:	256-845-4499

Provider Business Practice Location Address
First Line	:	1906 GLENN BLVD SW
Second Line	:
City	:	FORT PAYNE
State	:	AL
Zip	:	35968-3545
Country	:	US
Telephone Number	:	256-845-7555
Fax Number	:	256-845-4499

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	07/15/2010

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