1679701023 NPI number — KENNETH ANDREW PEARSON MD

Table of content: KENNETH ANDREW PEARSON MD (NPI 1679701023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679701023 NPI number — KENNETH ANDREW PEARSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEARSON
Provider First Name:
KENNETH
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
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:
1679701023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 MACCORKLE AVENUE
Provider Second Line Business Mailing Address:
SUITE B16
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25304
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:
3200 MACCORKLE AVE SE STE B16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25304-1227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-388-5848
Provider Business Practice Location Address Fax Number:
304-388-9654
Provider Enumeration Date:
06/24/2009

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: 207P00000X , with the licence number:  323657 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 28966 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 323657 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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