1902800758 NPI number — RETINA CONSULTANTS, PLLC

Table of content: (NPI 1902800758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902800758 NPI number — RETINA CONSULTANTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA CONSULTANTS, 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:
1902800758
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3970
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:
25339-3970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-346-4400
Provider Business Mailing Address Fax Number:
304-346-0704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
331 LAIDLEY ST
Provider Second Line Business Practice Location Address:
STE 301
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25301-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-346-4400
Provider Business Practice Location Address Fax Number:
304-346-0704
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DUNDERVILL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
FRANK
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
304-346-4400

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  002 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0107X , 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: 0008255000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0939668 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65927964 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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