Provider Demographics
NPI:1629731757
Name:ONLINE DOCTOR OFFICE
Entity Type:Organization
Organization Name:ONLINE DOCTOR OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CIO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-639-9809
Mailing Address - Street 1:30 N GOULD ST STE N
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6317
Mailing Address - Country:US
Mailing Address - Phone:800-222-9375
Mailing Address - Fax:740-738-0707
Practice Address - Street 1:30 N GOULD ST STE N
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6317
Practice Address - Country:US
Practice Address - Phone:800-222-9375
Practice Address - Fax:740-738-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service