Provider Demographics
NPI:1891779047
Name:ALLEN, MARK WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:333 LAIDLEY ST
Mailing Address - Street 2:HMG HOSPITALIST OFFICE
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1614
Mailing Address - Country:US
Mailing Address - Phone:304-347-6116
Mailing Address - Fax:304-347-6117
Practice Address - Street 1:333 LAIDLEY ST
Practice Address - Street 2:HMG HOSPITALIST OFFICE
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1614
Practice Address - Country:US
Practice Address - Phone:304-347-6116
Practice Address - Fax:304-347-6117
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2010-04-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV19909208000000X, 207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1891779047OtherBLUE SHIELD
WV3002489000Medicaid
WVAL4045497Medicare PIN
WV3002489000Medicaid
4045491Medicare ID - Type Unspecified
H33838Medicare UPIN