1710986658 NPI number — DR. MARK A MYERS M.D.

Table of content: DR. MARK A MYERS M.D. (NPI 1710986658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710986658 NPI number — DR. MARK A MYERS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYERS
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1710986658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RR 3 BOX 142
Provider Second Line Business Mailing Address:
HUNT CLUB PLAZA
Provider Business Mailing Address City Name:
RIDGELEY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26753-9500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-726-4501
Provider Business Mailing Address Fax Number:
304-726-4051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RR 3 BOX 142
Provider Second Line Business Practice Location Address:
HUNT CLUB PLAZA
Provider Business Practice Location Address City Name:
RIDGELEY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26753-9500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-726-4501
Provider Business Practice Location Address Fax Number:
304-726-4051
Provider Enumeration Date:
07/20/2005

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: 207Q00000X , with the licence number:  13567 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: D32235 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0056925000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41843503 . This is a "CAREFIRST BC BS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: E458 0007 . This is a "BLUE CHOICE BC BS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 000513375 . This is a "MT. STATE BC BS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 080188048 . This is a "TRAVELERS MEDICARE" identifier . This identifiers is of the category "OTHER".




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