Basic Information
| Provider Information | |||||||||
| NPI: | 1073528386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | TOMMY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 221249 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282221249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043321291 | ||||||||
| FaxNumber: | 7009261832 | ||||||||
| Practice Location | |||||||||
| Address1: | 3623 LATROBE DR STE 216 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282112117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043321291 | ||||||||
| FaxNumber: | 7049261832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 09/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | ME11044 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | 9300769 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | ME11044 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0904X | ME11044 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | ME11044 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | ME11044 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | ME11044 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 110445 | 05 | SC | MEDICAID | 89063U2 | 05 | NC | MEDICAID | 2001 | 01 | SC | MEDICARE GROUP | OTHER |