Basic Information
| Provider Information | |||||||||
| NPI: | 1194785642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEISMAN | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 N MOUNTAIN RD | ||||||||
| Address2: | |||||||||
| City: | PLAINVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060621848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MATTHEW ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403737828 | ||||||||
| FaxNumber: | 7403735898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 47702 | CT | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208800000X | 35.097897 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 000000728272 | 01 | OH | ANTHEM | OTHER | 0052750 | 05 | OH | MEDICAID | 3810021225 | 05 | WV | MEDICAID | P01216329 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000727239 | 01 | OH | ANTHEM | OTHER |