1154420990 NPI number — DR. STEPHANUS JOHANNES SERFONTEIN MD

Table of content: DR. STEPHANUS JOHANNES SERFONTEIN MD (NPI 1154420990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154420990 NPI number — DR. STEPHANUS JOHANNES SERFONTEIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERFONTEIN
Provider First Name:
STEPHANUS
Provider Middle Name:
JOHANNES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1154420990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 MACCORKLE SEAVE B16
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:
25304-1227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-388-5848
Provider Business Mailing Address Fax Number:
304-388-9654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2418 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PT PLEASANT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25550-1528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-675-6835
Provider Business Practice Location Address Fax Number:
304-675-6849
Provider Enumeration Date:
09/21/2006

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: 207R00000X , with the licence number:  21778 , 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: 2548390 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810001774 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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