Provider Demographics
NPI:1346434867
Name:PROFESSIONAL MEDICAL REHABILITATION INC.
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL REHABILITATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:J DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:304-983-7766
Mailing Address - Street 1:460 MYLAN PARK LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-2281
Mailing Address - Country:US
Mailing Address - Phone:304-983-7766
Mailing Address - Fax:304-983-7768
Practice Address - Street 1:460 MYLAN PARK LN
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-2281
Practice Address - Country:US
Practice Address - Phone:304-983-7766
Practice Address - Fax:304-983-7768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV16960208100000X
WVPT002617225100000X
WVPTA001299225200000X
WV1999 0357225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV223202OtherCARELINK
WV001371360OtherMT STATE BCBS
WV3810007971Medicaid
WV000578387OtherHIGHMARK BLUESHIELD
WV223202OtherCARELINK
WVCD7963Medicare PIN