Provider Demographics
NPI:1003093212
Name:GARY L. POLING, D.O.
Entity Type:Organization
Organization Name:GARY L. POLING, D.O.
Other - Org Name:FAMILY MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLING
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-929-6020
Mailing Address - Street 1:25 MALLARD CT
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3664
Mailing Address - Country:US
Mailing Address - Phone:304-929-6020
Mailing Address - Fax:
Practice Address - Street 1:25 MALLARD CT
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3664
Practice Address - Country:US
Practice Address - Phone:304-929-6020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV1221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0053014000Medicaid
WVE92806Medicare UPIN