Provider Demographics
NPI:1710974159
Name:GLEN DALE MEDICINE & PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:GLEN DALE MEDICINE & PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYS/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:HESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-845-1500
Mailing Address - Street 1:908 CHESTNUT DR
Mailing Address - Street 2:
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1002
Mailing Address - Country:US
Mailing Address - Phone:304-843-0036
Mailing Address - Fax:
Practice Address - Street 1:407 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1536
Practice Address - Country:US
Practice Address - Phone:304-845-1500
Practice Address - Fax:304-845-1552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV-001207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV=========OtherTAX ID