Basic Information
| Provider Information | |||||||||
| NPI: | 1538322029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEBER | ||||||||
| OtherFirstName: | DREW | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035938441 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2008 | ||||||||
| LastUpdateDate: | 10/14/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 706-L | MS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 21606 | MS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | P1709 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 304969402 | 05 | TX | MEDICAID | 751976930005 | 01 | TX | TRICARE | OTHER | P01070515 | 01 | TX | RAIL ROAD | OTHER | 750818167048 | 01 | TX | TRICARE | OTHER | 304969403 | 05 | TX | MEDICAID | 750818167022 | 01 | TX | TRICARE | OTHER | 304969404 | 05 | TX | MEDICAID | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 750818167015 | 01 | TX | TRICARE | OTHER | 8DD754 | 01 | TX | BCBS | OTHER | P01304488 | 01 | TX | RAIL ROAD | OTHER | 304969401 | 05 | TX | MEDICAID | 75-2616977-028 | 01 | TX | TRICARE | OTHER | P01279299 | 01 | TX | RAIL ROAD | OTHER | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 750818167044 | 01 | TX | TRICARE | OTHER | 8X8167 | 01 | TX | BCBS | OTHER | 8DD751 | 01 | TX | BCBS | OTHER | 8DU715 | 01 | TX | BCBS | OTHER |