=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073745634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST FLORIDA PLASTIC SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2009
-----------------------------------------------------
Last Update Date | 03/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 KINGSLEY AVE #200
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-215-5800
-----------------------------------------------------
Fax | 904-215-1211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 KINGSLEY AVE #200
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-215-5800
-----------------------------------------------------
Fax | 904-215-1211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ERIC ANDREW WEISS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 904-215-5800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME0062500
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------