Provider Demographics
NPI:1548217037
Name:CLARKSBURG SURGICAL SPECIALISTS
Entity Type:Organization
Organization Name:CLARKSBURG SURGICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-933-3855
Mailing Address - Street 1:527 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9008
Mailing Address - Country:US
Mailing Address - Phone:304-933-3855
Mailing Address - Fax:304-933-3859
Practice Address - Street 1:527 MEDICAL PARK DR
Practice Address - Street 2:STE 202
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9009
Practice Address - Country:US
Practice Address - Phone:304-933-3855
Practice Address - Fax:304-933-3859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18555208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV020411000Medicaid
WV18555OtherWV BUSINESS LICENSE
WV=========OtherTAX IDENTIFICATION NUMBER
WV9315541Medicare ID - Type Unspecified