Basic Information
| Provider Information | |||||||||
| NPI: | 1780612028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ERIC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635002 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004243672 | ||||||||
| FaxNumber: | 9543773042 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 JOHNSON STREEET | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549872000 | ||||||||
| FaxNumber: | 9549853453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME75622 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | ME75622 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 256533100 | 05 | FL | MEDICAID | 46732 | 01 | FL | BLUE SHIELD | OTHER |