=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619969631
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GALEN A WEISS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2005
-----------------------------------------------------
Last Update Date | 12/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1698 OLD LEBANON RD SUITE 3A
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-9662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-465-0632
-----------------------------------------------------
Fax | 270-789-6119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1698 OLD LEBANON RD SUITE 3A
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-9662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-465-0632
-----------------------------------------------------
Fax | 270-789-6119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 036117981
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 28849
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------