Provider Demographics
NPI:1235259938
Name:PINEVIEW DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:PINEVIEW DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:F
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:304-598-7546
Mailing Address - Street 1:1311 PINEVIEW DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3276
Mailing Address - Country:US
Mailing Address - Phone:304-598-7546
Mailing Address - Fax:304-225-7551
Practice Address - Street 1:1311 PINEVIEW DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3276
Practice Address - Country:US
Practice Address - Phone:304-598-7546
Practice Address - Fax:304-225-7551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17968261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001733619OtherBLUE CROSS BLUE SHIELD
WV1802385000Medicaid
WV001733619OtherBLUE CROSS BLUE SHIELD
WVPI9352871Medicare ID - Type Unspecified