Provider Demographics
NPI:1619090743
Name:BURNSVILLE MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:BURNSVILLE MEDICAL CENTER PLLC
Other - Org Name:BRAXTON PRIMARY HEALTH CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KATINY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-853-2278
Mailing Address - Street 1:110 MUNICIPAL STREET
Mailing Address - Street 2:PO BOX 424
Mailing Address - City:BURNSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26335-0424
Mailing Address - Country:US
Mailing Address - Phone:304-853-2278
Mailing Address - Fax:304-853-2520
Practice Address - Street 1:110 MUNICIPAL STREET
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26335-0424
Practice Address - Country:US
Practice Address - Phone:304-853-2278
Practice Address - Fax:304-853-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17332207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0034771000Medicaid
WV0075944000Medicaid
WV0075944000Medicaid
WVBU5138841Medicare PIN
WVF60719Medicare UPIN
WVBU9371111Medicare PIN
WVKA2029191Medicare PIN
WVKA0751213Medicare PIN