Basic Information
Provider Information | |||||||||
NPI: | 1578543799 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEAVER | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | WAIDE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 102222 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303682222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2392748200 | ||||||||
FaxNumber: | 2392783350 | ||||||||
Practice Location | |||||||||
Address1: | 3000 MEDICAL PARK DR STE 250 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336134679 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136326220 | ||||||||
FaxNumber: | 8139715893 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2006 | ||||||||
LastUpdateDate: | 09/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | ME87855 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | ME87855 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 274866500 | 05 | FL |   | MEDICAID | P00727037 | 01 | FL | RR MEDICARE | OTHER |