1285694125 NPI number — TUG VALLEY DIGESTIVE DISORDER CENTER INC

Table of content: (NPI 1285694125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285694125 NPI number — TUG VALLEY DIGESTIVE DISORDER CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TUG VALLEY DIGESTIVE DISORDER CENTER INC
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:
1285694125
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 LOGAN ST
Provider Second Line Business Mailing Address:
STE 42
Provider Business Mailing Address City Name:
WILLIAMSON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
41514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-235-3590
Provider Business Mailing Address Fax Number:
304-235-3592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 LOGAN ST
Provider Second Line Business Practice Location Address:
STE 42
Provider Business Practice Location Address City Name:
WILLIAMSON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-235-3590
Provider Business Practice Location Address Fax Number:
304-235-3592
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CORTAS
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MD OWNER OF PRACTICE
Authorized Official Telephone Number:
304-235-3590

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  19129 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X , with the licence number: 34274 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 64942030 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0088462000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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