=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053550186
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | G MARC WETHERINGTON MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2009
-----------------------------------------------------
Last Update Date | 01/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 E 2ND AVE
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30161-3224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-235-5119
-----------------------------------------------------
Fax | 706-235-5259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 E 2ND AVE
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30161-3224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-235-5119
-----------------------------------------------------
Fax | 706-235-5259
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | KELLIE BLACKMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-748-0309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 030690
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------