1467524082 NPI number — GREENBRIER VALLEY ENT PLLC

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 1467524082 NPI number — GREENBRIER VALLEY ENT PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREENBRIER VALLEY ENT 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:
1467524082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 902
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24901-0902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-520-4991
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 TAYLOR LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RONCEVERTE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24970-1337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-520-4991
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
304-645-0870

Provider Taxonomy Codes

  • Taxonomy code: 207YS0123X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1071033 . This is a "BRICK STREET W/COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 129458 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001916386 . This is a "MTN ST BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1306817689 . This is a "UNISYS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 611994100 . This is a "FEDERAL BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7786898 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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