Provider Demographics
NPI:1639113780
Name:WITHERELL, JAMES E (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:WITHERELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-992-0060
Mailing Address - Fax:740-992-5762
Practice Address - Street 1:88 E MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:OH
Practice Address - Zip Code:45769-9569
Practice Address - Country:US
Practice Address - Phone:740-992-0060
Practice Address - Fax:740-992-5762
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-04-3845207Q00000X
WV19421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0401489OtherMOLINA MEDICAID
001714087OtherMOUNTAIN STATE BCBS
080082297OtherRR MEDICARE
OH299449901OtherTRI CARE
000000007728OtherANTHEM BCBS
OH0401489Medicaid
OH310917085097OtherCARESOURCE MEDICAID
OH000000181976OtherUNISON MEDICAID
WV0056199000Medicaid
080082297OtherRR MEDICARE
001714087OtherMOUNTAIN STATE BCBS
WV0466774Medicare PIN