Provider Demographics
NPI:1285855254
Name:OHIO VALLEY COLON AND RECTAL SURGEONS PLLC
Entity Type:Organization
Organization Name:OHIO VALLEY COLON AND RECTAL SURGEONS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-238-0212
Mailing Address - Street 1:PO BOX 6493
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-238-0212
Mailing Address - Fax:304-238-0215
Practice Address - Street 1:76 SIXTEENTH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3660
Practice Address - Country:US
Practice Address - Phone:304-238-0212
Practice Address - Fax:304-238-0215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1806640000Medicaid
OH2289867Medicaid
WV1806640000Medicaid
OH2289867Medicaid