Provider Demographics
NPI:1467439463
Name:RHEUMATOLOGY AND PULMONARY CLINIC PLLC
Entity Type:Organization
Organization Name:RHEUMATOLOGY AND PULMONARY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:S
Authorized Official - Last Name:FONDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-256-0242
Mailing Address - Street 1:421 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2805
Mailing Address - Country:US
Mailing Address - Phone:304-256-0242
Mailing Address - Fax:304-256-0244
Practice Address - Street 1:421 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2805
Practice Address - Country:US
Practice Address - Phone:304-256-0242
Practice Address - Fax:304-256-0244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17491174400000X
WV18402174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1801602000Medicaid
WV001711048OtherBLUE CROSS
WV1805604000Medicaid
WV0795732Medicare ID - Type Unspecified
WV1801602000Medicaid
WVE33514Medicare UPIN
WV0755593Medicare ID - Type Unspecified