Provider Demographics
NPI:1891886636
Name:CHARLESTON FAMILY HEALTH ASSOC
Entity Type:Organization
Organization Name:CHARLESTON FAMILY HEALTH ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-345-8500
Mailing Address - Street 1:1218 VIRGINIA STREET EAST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301
Mailing Address - Country:US
Mailing Address - Phone:304-345-8500
Mailing Address - Fax:304-345-8979
Practice Address - Street 1:1218 VIRGINIA STREET EAST
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-345-8500
Practice Address - Fax:304-345-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17020207Q00000X
WV17129207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011206000Medicaid
WV0011206000Medicaid