Provider Demographics
NPI:1750310280
Name:CHARLESTON FAMILY PRACTICE GROUP
Entity Type:Organization
Organization Name:CHARLESTON FAMILY PRACTICE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-342-8513
Mailing Address - Street 1:1220 LEE ST E STE 201
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1864
Mailing Address - Country:US
Mailing Address - Phone:304-342-8513
Mailing Address - Fax:304-342-8147
Practice Address - Street 1:1220 LEE ST E STE 201
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1864
Practice Address - Country:US
Practice Address - Phone:304-342-8513
Practice Address - Fax:304-342-8147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11909207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D71721Medicare UPIN
P75586Medicare UPIN
WVA72111Medicare UPIN
9934032Medicare PIN
I29420Medicare UPIN