Provider Demographics
NPI:1548348923
Name:WEBER, MARY BERNADETTE (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:BERNADETTE
Last Name:WEBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BERNADETTE
Other - Last Name:JEDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 50546
Mailing Address - Street 2:2510 EAST 15TH STREET SUITE 2
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609
Mailing Address - Country:US
Mailing Address - Phone:307-235-8986
Mailing Address - Fax:
Practice Address - Street 1:2510 EAST 15TH ST SUITE 2
Practice Address - Street 2:WYOMING MEDICAL CENTER
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601
Practice Address - Country:US
Practice Address - Phone:307-577-2124
Practice Address - Fax:307-234-0306
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6196A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E85289Medicare UPIN
WY20156Medicare ID - Type Unspecified