Provider Demographics
NPI:1699819219
Name:E J SALON MD INC
Entity Type:Organization
Organization Name:E J SALON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRSIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SALON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-252-8541
Mailing Address - Street 1:200 RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-5944
Mailing Address - Country:US
Mailing Address - Phone:304-252-8541
Mailing Address - Fax:304-253-2507
Practice Address - Street 1:200 RALEIGH AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-5944
Practice Address - Country:US
Practice Address - Phone:304-252-8541
Practice Address - Fax:304-253-2507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18381207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001722335OtherBLUE CROSS BLUE SHIELD
WV0079492000Medicaid
WV0079492000Medicaid
WV0812202Medicare PIN