Provider Demographics
NPI:1659432631
Name:WHITEHALL MEDICAL PLLC
Entity Type:Organization
Organization Name:WHITEHALL MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:VASICEK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-363-6600
Mailing Address - Street 1:177 MIDDLETOWN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8216
Mailing Address - Country:US
Mailing Address - Phone:304-363-6600
Mailing Address - Fax:304-363-7700
Practice Address - Street 1:177 MIDDLETOWN RD
Practice Address - Street 2:SUITE 1
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8216
Practice Address - Country:US
Practice Address - Phone:304-363-6600
Practice Address - Fax:304-363-7700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1552208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2411485OtherGROUP
WV3810006289Medicaid
WV001711083OtherGROUP BCBS
WVWM9340081Medicare ID - Type UnspecifiedGROUP