Provider Demographics
NPI:1427034529
Name:RADER, DANNY (MD)
Entity Type:Individual
Prefix:DR
First Name:DANNY
Middle Name:
Last Name:RADER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ALEX LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2952
Mailing Address - Country:US
Mailing Address - Phone:304-734-2040
Mailing Address - Fax:304-734-2047
Practice Address - Street 1:4602 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1848
Practice Address - Country:US
Practice Address - Phone:304-205-7535
Practice Address - Fax:304-205-7536
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14752207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0051779000Medicaid
WV1042844OtherWV DWC
WV000651768OtherBLUE CROSS BLUE SHIELD
WV930122358Medicare PIN
WV0622664Medicare PIN
WV0622666Medicare PIN
WV1042844OtherWV DWC
WV000651768OtherBLUE CROSS BLUE SHIELD
WV930122360Medicare PIN
WV930122359Medicare PIN