=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669729851
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEISS PEDIATRICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2012
-----------------------------------------------------
Last Update Date | 08/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2082 MESQUITE AVE SUITE A-102
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-6710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-680-1264
-----------------------------------------------------
Fax | 982-680-1265
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11123
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-4002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-402-1000
-----------------------------------------------------
Fax | 617-402-1099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | DR. PRABHA SWAMY WEISS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 928-680-1264
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------