Provider Demographics
NPI:1275585739
Name:PAR WELLNESS CORPORATION
Entity Type:Organization
Organization Name:PAR WELLNESS CORPORATION
Other - Org Name:BRIDGEPORT FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ROMANO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-848-0338
Mailing Address - Street 1:1221 JOHNSON AVE
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1392
Mailing Address - Country:US
Mailing Address - Phone:304-848-0338
Mailing Address - Fax:
Practice Address - Street 1:1221 JOHNSON AVE
Practice Address - Street 2:SUITE 1100
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1392
Practice Address - Country:US
Practice Address - Phone:304-848-0338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVDF7112OtherRAILROAD MEDICARE
WV3810010298Medicaid
WV=========OtherTAX ID NUMBER
WV3810010298Medicaid