=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548393630
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BO WEDDLE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 WESTERN HILLS DR
-----------------------------------------------------
City | PARKERSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26105-8122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-420-1300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 SANDHILL RD APT 1
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-8782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-350-2448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2611
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------