Provider Demographics
NPI:1043222961
Name:EYE AND EAR CLINIC PHYSICIANS, INC
Entity Type:Organization
Organization Name:EYE AND EAR CLINIC PHYSICIANS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR,CPA
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:ARVON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-353-0303
Mailing Address - Street 1:1306 KANAWHA BLVD E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-3001
Mailing Address - Country:US
Mailing Address - Phone:304-353-0222
Mailing Address - Fax:304-353-0218
Practice Address - Street 1:1306 KANAWHA BLVD E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3001
Practice Address - Country:US
Practice Address - Phone:304-353-0222
Practice Address - Fax:304-353-0218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00848207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001157004Medicaid
WV0001157004Medicaid