Provider Demographics
NPI:1598786592
Name:ROLAND F CHALIFOUX JR DO PLLC
Entity Type:Organization
Organization Name:ROLAND F CHALIFOUX JR DO PLLC
Other - Org Name:VALLEY PAIN MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:F
Authorized Official - Last Name:CHALIFOUX JR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-242-4004
Mailing Address - Street 1:1001 W BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:MCMECHEN
Mailing Address - State:WV
Mailing Address - Zip Code:26040-1503
Mailing Address - Country:US
Mailing Address - Phone:304-242-4004
Mailing Address - Fax:304-242-8004
Practice Address - Street 1:1001 W BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:MCMECHEN
Practice Address - State:WV
Practice Address - Zip Code:26040-1503
Practice Address - Country:US
Practice Address - Phone:304-242-4004
Practice Address - Fax:304-242-8004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2077207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2625001Medicaid
WV3810004422Medicaid
WV3810004422Medicaid
OH2625001Medicaid