Healthcare Provider Details

I. General information

NPI: 1588767750
Provider Name (Legal Business Name): PHYSICAL MEDICINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1642 ROSWELL RD
MARIETTA GA
30062-3621
US

IV. Provider business mailing address

1642 ROSWELL RD
MARIETTA GA
30062-3621
US

V. Phone/Fax

Practice location:
  • Phone: 770-973-8800
  • Fax: 770-971-6962
Mailing address:
  • Phone: 770-973-8800
  • Fax: 770-971-6962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG00161
License Number StateGA

VIII. Authorized Official

Name: KENNETH S WEINER
Title or Position: PRESIDENT
Credential:
Phone: 770-973-8800