MEDICARE: DR. CHARLES EDWARD WEAVER JR. MD PHD

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	207T00000X	Neurological Surgery Physician	56242	GA

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
2	854350	OTHER		BCBS OF GA

General Provider Information

NPI Number	:	1801899554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES EDWARD WEAVER JR. MD PHD

Provider Business Mailing Address
First Line	:	2500 HOSPITAL BLVD
Second Line	:	STE 310
City	:	ROSWELL
State	:	GA
Zip	:	30076-4947
Country	:	US
Telephone Number	:	770-664-9600
Fax Number	:	770-664-9856

Provider Business Practice Location Address
First Line	:	470 NORTHSIDE CHEROKEE BLVD STE 170
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30115-8029
Country	:	US
Telephone Number	:	770-721-9540
Fax Number	:	770-721-9541

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

Provider Enumeration Date	:	05/25/2005
Last Update Date	:	02/26/2021

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