Provider Demographics
NPI:1093087611
Name:MCNEILLY, RICHARD A (DO, FCCP)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:MCNEILLY
Suffix:
Gender:M
Credentials:DO, FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 RECTER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-9663
Mailing Address - Country:US
Mailing Address - Phone:704-300-9443
Mailing Address - Fax:
Practice Address - Street 1:701 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1669
Practice Address - Country:US
Practice Address - Phone:304-369-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3010207R00000X, 207RP1001X
MST-2337207R00000X
SC90050207RP1001X
OH58-004978207RP1001X
MT115288207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022431Medicaid
VA1093087611Medicaid
TN103I115738Medicare PIN