=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922107911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER C. BOARDWINE DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 10/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 GORMAN AVE
-----------------------------------------------------
City | ELKINS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26241-3147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-636-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 812 GORMAN AVE
-----------------------------------------------------
City | ELKINS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26241-3181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-637-9302
-----------------------------------------------------
Fax | 304-637-9306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 38203
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 3019
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------