Basic Information
| Provider Information | |||||||||
| NPI: | 1497910061 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WECKESSER | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARDYZA | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 745 HASKINS RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434021600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193537069 | ||||||||
| FaxNumber: | 4193537076 | ||||||||
| Practice Location | |||||||||
| Address1: | 970 W WOOSTER ST | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434022643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193526890 | ||||||||
| FaxNumber: | 4193532415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35097856 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0061307 | 05 | OH | MEDICAID |