Basic Information
| Provider Information | |||||||||
| NPI: | 1801899554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 HOSPITAL BLVD | ||||||||
| Address2: | STE 310 | ||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300764947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706649600 | ||||||||
| FaxNumber: | 7706649856 | ||||||||
| Practice Location | |||||||||
| Address1: | 470 NORTHSIDE CHEROKEE BLVD STE 170 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301158029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707219540 | ||||||||
| FaxNumber: | 7707219541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2005 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 56242 | GA | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 642893452A | 05 | GA | MEDICAID | 854350 | 01 | BCBS OF GA | OTHER |