Healthcare Provider Details

I. General information

NPI: 1437161239
Provider Name (Legal Business Name): EDWARD GLENN WEBER MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 GRAND CENTRAL MALL SUITE 1
VIENNA WV
26105-4100
US

IV. Provider business mailing address

415 36TH ST SUITE 100
PARKERSBURG WV
26101-1005
US

V. Phone/Fax

Practice location:
  • Phone: 304-865-6777
  • Fax: 304-865-6780
Mailing address:
  • Phone: 304-917-3660
  • Fax: 304-917-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number001333
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT006713
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: