1730485376 NPI number — FRANK EDWARD IVAN III P.T.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730485376 NPI number — FRANK EDWARD IVAN III P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVAN
Provider First Name:
FRANK
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
P.T.
Provider Gender Code:
M

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:
1730485376
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
296 BIG TIMBER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPON BRIDGE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26711-8943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-860-5366
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13857 APPLE HARVEST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTINSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25403-6199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
681-248-5384
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2305206758 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 004477 , 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: 2307001197 . This is a "DIRECT ACCESS CERTIFICATION" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: K949 - 0077 . This is a "CAREFIRST" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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