Provider Demographics
NPI:1821123159
Name:OLD MILL INTERNISTS, LTD
Entity Type:Organization
Organization Name:OLD MILL INTERNISTS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KITTY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MISIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-263-7591
Mailing Address - Street 1:PO BOX 948
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25402-0948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:304-263-8318
Practice Address - Street 1:2008 PROFESSIONAL COURT
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-7591
Practice Address - Fax:304-263-8318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11538207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0082852000Medicaid
WV0008767001Medicaid
WV9919401Medicare ID - Type Unspecified
WV0082852000Medicaid