1346241874 NPI number — CHERYL P ENTRESS MD

Table of content: CHERYL P ENTRESS MD (NPI 1346241874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346241874 NPI number — CHERYL P ENTRESS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENTRESS
Provider First Name:
CHERYL
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1346241874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
58 16TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26003-3660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-234-2116
Provider Business Mailing Address Fax Number:
304-234-2030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
58 16TH ST
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:
26003-3660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-234-2116
Provider Business Practice Location Address Fax Number:
304-234-2030
Provider Enumeration Date:
08/09/2005

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:  09089 , 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: 0779644 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5503570579J26 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0055318000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09089D . This is a "HEALTH PLAN OF UPPER OH V" identifier . This identifiers is of the category "OTHER".
  • Identifier: 55035705705 . This is a "WV COMPENSATION" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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