Basic Information
| Provider Information | |||||||||
| NPI: | 1922024280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WU | ||||||||
| FirstName: | BO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 171181 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381871181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016822872 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1068 CRESTHAVEN RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381190800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016826828 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 10/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD35405 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3867178 | 05 | TN | MEDICAID | 173743001 | 01 | AR | ARKANSAS MEDICAID | OTHER | 050084189 | 01 | RR MEDICAR | OTHER | 04479265 | 01 | MS | MS MEDICAID | OTHER | 2000136 | 01 | TN | UNITED HEALTHCARE | OTHER | 4015934 | 01 | TN | BLUE CROSS | OTHER |