Provider Demographics
NPI:1043275308
Name:WEISS, PHILIP S (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:S
Last Name:WEISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE HEARN DR NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1523
Mailing Address - Country:US
Mailing Address - Phone:404-256-3178
Mailing Address - Fax:404-256-3583
Practice Address - Street 1:1100 LAKE HEARN DR NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1523
Practice Address - Country:US
Practice Address - Phone:404-256-3178
Practice Address - Fax:404-256-3583
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038398208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
499492OtherBLUE CROSS BLUE SHIELD
5033138OtherAETNA CAPITATED
040470OtherGREAT WEST
569351OtherAETNA
691304OtherCIGNA HEALTHCARE