Provider Demographics
NPI:1497709018
Name:MAGNUSSEN, JAMES R (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:MAGNUSSEN
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5415
Mailing Address - Fax:740-446-5958
Practice Address - Street 1:90 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5415
Practice Address - Fax:740-446-5958
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-4973207Y00000X
WV13013207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0101035000Medicaid
OH310917085093OtherCARESOURCE MEDICAID
000000006800OtherANTHEM BCBS
OH0366376OtherMOLINA MEDICAID
OH0366376Medicaid
040003160OtherRR MEDICARE
001714044OtherMOUNTAIN STATE BCBS
OH000000181417OtherUNISON MEDICAID
OH000000181417OtherUNISON MEDICAID
040003160OtherRR MEDICARE
WV0452342Medicare PIN