Provider Demographics
NPI:1083603336
Name:IRVIN, RICHARD A
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:IRVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 NATIONAL RD
Mailing Address - Street 2:P.O. BOX 2079
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5247
Mailing Address - Country:US
Mailing Address - Phone:304-242-2303
Mailing Address - Fax:304-242-4231
Practice Address - Street 1:2129 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5247
Practice Address - Country:US
Practice Address - Phone:304-242-2303
Practice Address - Fax:304-242-4231
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0205733701OtherWV COMP
WV0053352001OtherPAAS
WV0053352001Medicaid
WV153563OtherCARELINK
WV1279COtherHEALTH PLAN OF THE UPPER
OH2310412Medicaid
WV001705854OtherBLUE CROSS/BLUE SHIELD/MT
WVSP03641Medicare PIN
WV1279COtherHEALTH PLAN OF THE UPPER