Provider Demographics
NPI:1053550186
Name:G MARC WETHERINGTON MD LLC
Entity type:Organization
Organization Name:G MARC WETHERINGTON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-748-0309
Mailing Address - Street 1:406 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3224
Mailing Address - Country:US
Mailing Address - Phone:706-235-5119
Mailing Address - Fax:706-235-5259
Practice Address - Street 1:406 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3224
Practice Address - Country:US
Practice Address - Phone:706-235-5119
Practice Address - Fax:706-235-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030690208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G701261Medicare PIN