Provider Demographics
NPI:1497103386
Name:SOUTHERN WV MEDICAL AND SURGICAL SPECIALISTS PLLC
Entity Type:Organization
Organization Name:SOUTHERN WV MEDICAL AND SURGICAL SPECIALISTS PLLC
Other - Org Name:SOUTHERN WV ENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-929-6930
Mailing Address - Street 1:PO BOX 5482
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-7506
Mailing Address - Country:US
Mailing Address - Phone:304-929-6930
Mailing Address - Fax:304-929-6935
Practice Address - Street 1:206 SKYLAR DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9383
Practice Address - Country:US
Practice Address - Phone:681-318-3540
Practice Address - Fax:877-712-1319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23770207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty