Provider Demographics
NPI:1053384438
Name:VEDDER, CASEY A (PT)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:A
Last Name:VEDDER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 W INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-3500
Mailing Address - Country:US
Mailing Address - Phone:336-783-9400
Mailing Address - Fax:336-783-9406
Practice Address - Street 1:847 WESTLAKE DRIVE
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2703
Practice Address - Country:US
Practice Address - Phone:336-783-9400
Practice Address - Fax:336-783-9406
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
196659OtherBCBSNC
NC7212439Medicaid
196659OtherBCBSNC