1083603336 NPI number — RICHARD A IRVIN

Table of content: RICHARD A IRVIN (NPI 1083603336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083603336 NPI number — RICHARD A IRVIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRVIN
Provider First Name:
RICHARD
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1083603336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2129 NATIONAL RD
Provider Second Line Business Mailing Address:
P.O. BOX 2079
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26003-5247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-242-2303
Provider Business Mailing Address Fax Number:
304-242-4231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2129 NATIONAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003-5247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-242-2303
Provider Business Practice Location Address Fax Number:
304-242-4231
Provider Enumeration Date:
10/19/2005

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:  1279 , 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: 0205733701 . This is a "WV COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0053352001 . This is a "PAAS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0053352001 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 153563 . This is a "CARELINK" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1279C . This is a "HEALTH PLAN OF THE UPPER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 2310412 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001705854 . This is a "BLUE CROSS/BLUE SHIELD/MT" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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