1154320869 NPI number — MOUNTAINEER RADIOLOGISTS INC

Table of content: (NPI 1154320869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154320869 NPI number — MOUNTAINEER RADIOLOGISTS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAINEER RADIOLOGISTS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154320869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25324-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-951-1588
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1306 KANAWHA BLVD E
Provider Second Line Business Practice Location Address:
BUILDING 2
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25301-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-951-1588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ZEKAN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-951-1588

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810006507 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1154320869 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001711957 . This is a "BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810006508 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810002431 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".