Provider Demographics
NPI:1508820861
Name:WIRTS, AMY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LEE
Last Name:WIRTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 KANAWHA BLVD W
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-2536
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
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:304-925-4777
Practice Address - Fax:304-925-4870
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19420207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00206389OtherRAILROAD MEDICARE
WV3810000467Medicaid
WI4031865Medicare PIN
WVWI4031862Medicare ID - Type Unspecified
WVH24263Medicare UPIN
WI4031866Medicare PIN
P00206389Medicare PIN