Provider Demographics
NPI:1548393630
Name:WEDDLE, BO
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:WEDDLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SANDHILL RD APT 1
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-8782
Mailing Address - Country:US
Mailing Address - Phone:740-350-2448
Mailing Address - Fax:
Practice Address - Street 1:3 WESTERN HILLS DR
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26105-8122
Practice Address - Country:US
Practice Address - Phone:304-420-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0002106000Medicaid
WV0002106000Medicaid