Healthcare Provider Details

I. General information

NPI: 1528063997
Provider Name (Legal Business Name): TERRY DEAN WEAVER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 1ST ST NE STE 1
WESSINGTON SPRINGS SD
57382-2163
US

IV. Provider business mailing address

602 1ST ST NE STE 1
WESSINGTON SPRINGS SD
57382-2163
US

V. Phone/Fax

Practice location:
  • Phone: 605-539-1778
  • Fax:
Mailing address:
  • Phone: 605-539-1778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberE-3438
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberE-3438
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: