=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194141085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NANCY CANTER WEINER MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2014
-----------------------------------------------------
Last Update Date | 03/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 COLLIER RD NW SUITE 5030
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-350-8941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 COLLIER RD NW SUITE 5030
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-350-8941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. NANCY CANTER WEINER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 404-350-8941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 033749
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 033749
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------