Basic Information
| Provider Information | |||||||||
| NPI: | 1396855615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | MCGRATH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P O BOX 1000 DEPT 457 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012753662 | ||||||||
| FaxNumber: | 9012710155 | ||||||||
| Practice Location | |||||||||
| Address1: | 57 GERMANTOWN CT STE 204 | ||||||||
| Address2: | |||||||||
| City: | CORDOVA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017587888 | ||||||||
| FaxNumber: | 9012666445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 37435 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00010284 | 01 | TN | RAILROAD MEDICARE | OTHER | 3880911 | 05 | TN | MEDICAID |