Provider Demographics
NPI:1720041171
Name:MID-OHIO VALLEY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:MID-OHIO VALLEY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:HAYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-485-4439
Mailing Address - Street 1:800 GRAND CENTRAL MALL
Mailing Address - Street 2:SUITE 4
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4131
Mailing Address - Country:US
Mailing Address - Phone:304-485-3300
Mailing Address - Fax:304-485-3317
Practice Address - Street 1:800 GRAND CENTRAL MALL
Practice Address - Street 2:SUITE 4
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-4131
Practice Address - Country:US
Practice Address - Phone:304-485-3300
Practice Address - Fax:304-485-6489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01387207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2160325Medicaid
WV4000315000Medicaid
WV4000315000Medicaid
WV9307481Medicare PIN