Basic Information
| Provider Information | |||||||||
| NPI: | 1245444074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIMER | ||||||||
| FirstName: | MATHEW | ||||||||
| MiddleName: | BENJAMIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2585 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257031642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045253334 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | 1347 HILLVIEW DR | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255411513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047431407 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 09/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.091875 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 22530 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100228730 | 05 | KY | MEDICAID | 3810012382 | 05 | WV | MEDICAID | 2849092 | 05 | OH | MEDICAID |