Basic Information
| Provider Information | |||||||||
| NPI: | 1811124621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658089007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172697900 | ||||||||
| FaxNumber: | 4172697990 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E PRIMROSE ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172697900 | ||||||||
| FaxNumber: | 4172697990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2009 | ||||||||
| LastUpdateDate: | 12/27/2018 | ||||||||
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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 | 207V00000X | 2009013838 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1811124621 | 05 | MO | MEDICAID | 200007803 | 05 | MO | MEDICAID |