Provider Demographics
NPI:1174795900
Name:GORDON R. WEIGLE, MD PA
Entity type:Organization
Organization Name:GORDON R. WEIGLE, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:REESE
Authorized Official - Last Name:WEIGLE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:803-533-0091
Mailing Address - Street 1:1717 VILLAGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2475
Mailing Address - Country:US
Mailing Address - Phone:803-533-0091
Mailing Address - Fax:803-533-6084
Practice Address - Street 1:1717 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2475
Practice Address - Country:US
Practice Address - Phone:803-533-0091
Practice Address - Fax:803-533-6084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC8901207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3708Medicaid
SC7659Medicare PIN