Provider Demographics
NPI:1407079551
Name:WV SPINE AND PAIN CLINIC
Entity Type:Organization
Organization Name:WV SPINE AND PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WEIXING
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GUO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-561-7879
Mailing Address - Street 1:PO BOX 58125
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25358-0125
Mailing Address - Country:US
Mailing Address - Phone:304-307-6618
Mailing Address - Fax:304-307-6619
Practice Address - Street 1:340 STATE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1365
Practice Address - Country:US
Practice Address - Phone:304-561-7879
Practice Address - Fax:304-307-6619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20962208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1841070000Medicaid
WVH68655Medicare UPIN
WVGU4089091Medicare ID - Type Unspecified