Provider Demographics
NPI:1346333168
Name:DR L E SYNER AND DR W M WINE ASSOC IN ORAL & MAXILLOFACIAL SURG INC,
Entity Type:Organization
Organization Name:DR L E SYNER AND DR W M WINE ASSOC IN ORAL & MAXILLOFACIAL SURG INC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUMATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-252-8609
Mailing Address - Street 1:750 STANAFORD RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-8737
Mailing Address - Country:US
Mailing Address - Phone:304-252-8609
Mailing Address - Fax:304-253-8870
Practice Address - Street 1:750 STANAFORD RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-8737
Practice Address - Country:US
Practice Address - Phone:304-252-8609
Practice Address - Fax:304-253-8870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0138270000Medicaid
WV0138303000Medicaid
WV0138303000Medicaid
WV0138270000Medicaid