Healthcare Provider Details

I. General information

NPI: 1356327829
Provider Name (Legal Business Name): RICHARD A. WEDDLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 MCINTIRE DR SUITE 310
BLOOMINGTON IN
47403-4221
US

IV. Provider business mailing address

2920 MCINTIRE DR SUITE 310
BLOOMINGTON IN
47403-4221
US

V. Phone/Fax

Practice location:
  • Phone: 812-331-0233
  • Fax: 812-331-0287
Mailing address:
  • Phone: 812-331-0233
  • Fax: 812-331-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01031299
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: