Basic Information
| Provider Information | |||||||||
| NPI: | 1962453530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N EAGLE CREEK DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592634341 | ||||||||
| FaxNumber: | 8592637441 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 TRADE ST | ||||||||
| Address2: | STE C | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405112610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592311176 | ||||||||
| FaxNumber: | 8592311186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 28932 | KY | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 64289325 | 05 | KY | MEDICAID |