1891756029 NPI number — GRAND CENTRAL FAMILY MEDICINE, P.L.L.C.

Table of content: (NPI 1891756029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891756029 NPI number — GRAND CENTRAL FAMILY MEDICINE, P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND CENTRAL FAMILY MEDICINE, P.L.L.C.
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:
1891756029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
418 GRAND PK DR
Provider Second Line Business Mailing Address:
SUITE 312
Provider Business Mailing Address City Name:
PARKERSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26101-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-422-3400
Provider Business Mailing Address Fax Number:
304-422-7893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
418 GRAND PK DR
Provider Second Line Business Practice Location Address:
SUITE 312
Provider Business Practice Location Address City Name:
PARKERSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26101-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-422-3400
Provider Business Practice Location Address Fax Number:
304-422-7893
Provider Enumeration Date:
03/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AVERY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-422-3400

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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