1619152436 NPI number — UNITED PHYSICIANS CARE INC

Table of content: (NPI 1619152436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619152436 NPI number — UNITED PHYSICIANS CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNITED PHYSICIANS CARE 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:
6
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:
1619152436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
686 S PIKE ST
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
SHINNSTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26431-1043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-624-4655
Provider Business Mailing Address Fax Number:
304-624-3918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1511 JOHNSON AVE
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-848-0702
Provider Business Practice Location Address Fax Number:
304-848-0705
Provider Enumeration Date:
12/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FORESTER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
304-624-4655

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  51D1071522 , 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: 3810010590 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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