1487927141 NPI number — MICHAEL FAMILY PRACTICE PLLC

Table of content: MADELINE CADLE BENNETT PHARMD (NPI 1710583802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487927141 NPI number — MICHAEL FAMILY PRACTICE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL FAMILY PRACTICE 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:
1487927141
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2014
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:
BERKELEY SPRINGS
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25411-3111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-258-8824
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2055 VALLEY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY SPRINGS
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-258-8824
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MICHAEL
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
304-258-8824

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2583 , 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: 3810023434 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2583 . This is a "WEST VIRGINIA LICENSE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3438686 . This is a "CIGNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".