Provider Demographics
NPI:1568682730
Name:SUSHIL K MEHROTRA MD INC
Entity Type:Organization
Organization Name:SUSHIL K MEHROTRA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-234-8559
Mailing Address - Street 1:2101 JACOB ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3800
Mailing Address - Country:US
Mailing Address - Phone:304-232-1122
Mailing Address - Fax:304-234-1873
Practice Address - Street 1:2101 JACOB ST
Practice Address - Street 2:STE 302
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3800
Practice Address - Country:US
Practice Address - Phone:304-232-1122
Practice Address - Fax:304-234-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0082671000Medicaid
WV4000018001Medicaid