1659391472 NPI number — TYGART VALLEY ORTHOPEDICS AND SPORTS MEDICINE, INC.

Table of content: (NPI 1659391472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659391472 NPI number — TYGART VALLEY ORTHOPEDICS AND SPORTS MEDICINE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TYGART VALLEY ORTHOPEDICS AND SPORTS MEDICINE, 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:
1659391472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 848220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02284-8220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-637-4509
Provider Business Mailing Address Fax Number:
304-637-5319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1502 HARRISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKINS
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26241-3327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-637-4509
Provider Business Practice Location Address Fax Number:
304-637-5319
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TOPPING
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
EDMOND
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
304-637-4509

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5110270001 . This is a "MEDICARE DME" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001710883 . This is a "BC/BS ID NUMBER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 4000084000 . This is a "MEDICAID ID NUMBER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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