Provider Demographics
NPI:1457449761
Name:SOUTH CHARLESTON PRIMARY CARE ASSOCIATES
Entity Type:Organization
Organization Name:SOUTH CHARLESTON PRIMARY CARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-744-4532
Mailing Address - Street 1:312 6TH AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1242
Mailing Address - Country:US
Mailing Address - Phone:304-744-4532
Mailing Address - Fax:304-744-3219
Practice Address - Street 1:312 6TH AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1242
Practice Address - Country:US
Practice Address - Phone:304-744-4532
Practice Address - Fax:304-744-3219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0009405000Medicaid
WV0009405000Medicaid