1255403002 NPI number — APPALACHIAN HIGHWAY MEDICAL & SURGICAL CLINIC, PLLC

Table of content: (NPI 1255403002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255403002 NPI number — APPALACHIAN HIGHWAY MEDICAL & SURGICAL CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APPALACHIAN HIGHWAY MEDICAL & SURGICAL CLINIC, PLLC
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:
1255403002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
APPALACHIAN HIGHWAY RT. 10 EAST PINEVILLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINEVILLE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24874-1274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-732-9045
Provider Business Mailing Address Fax Number:
304-732-9055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
APPALACHIAN HWY, RT. 10 EAST PINEVILLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24874-1274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-732-9045
Provider Business Practice Location Address Fax Number:
304-732-9055
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAO
Authorized Official First Name:
DOMINADOR
Authorized Official Middle Name:
YTI
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
304-732-9045

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  12700 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200001780 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 00182204 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0128304001 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57799 . This is a "UNICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1220372 . This is a "CHA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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