Provider Demographics
NPI:1053468900
Name:MARION LUNG CLINIC
Entity Type:Organization
Organization Name:MARION LUNG CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRASAD
Authorized Official - Middle Name:V
Authorized Official - Last Name:DEVABHAKTUNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-363-7773
Mailing Address - Street 1:1325 LOCUST AVE
Mailing Address - Street 2:SUITE 35
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1435
Mailing Address - Country:US
Mailing Address - Phone:304-363-7773
Mailing Address - Fax:304-363-7773
Practice Address - Street 1:1325 LOCUST AVE
Practice Address - Street 2:SUITE 35
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1435
Practice Address - Country:US
Practice Address - Phone:304-363-7773
Practice Address - Fax:304-363-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001710138OtherBCBS GROUP NUMBER
WV0009095000Medicaid
WV0009095000Medicaid