MEDICARE: KORRINE MARIE WEIDMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	NCO-000001	GA

General Provider Information

NPI Number	:	1962148965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KORRINE MARIE WEIDMAN

Provider Business Mailing Address
First Line	:	415 PADDOCK HILL CT
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30075-2150
Country	:	US
Telephone Number	:	845-399-5339
Fax Number	:

Provider Business Practice Location Address
First Line	:	5885 GLENRIDGE DR UNIT 100
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-5512
Country	:	US
Telephone Number	:	678-321-8546
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2022
Last Update Date	:	05/11/2022

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