Provider Demographics
NPI:1659585263
Name:WHITEHALL MEDICAL PLLC
Entity Type:Organization
Organization Name:WHITEHALL MEDICAL PLLC
Other - Org Name:RICHARD E VASICEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER SINGLE 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:
Authorized Official - Phone:304-363-6600
Mailing Address - Street 1:60 ROXBURY ROAD
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:WV
Mailing Address - Zip Code:26554-3430
Mailing Address - Country:US
Mailing Address - Phone:304-363-6600
Mailing Address - Fax:304-363-7700
Practice Address - Street 1:60 ROXBURY ROAD
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:WV
Practice Address - Zip Code:26554-3430
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:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5100942930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006289Medicaid
WV3810006289Medicaid