Provider Demographics
NPI:1932122512
Name:SURFACE, PHILLIP D (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D
Last Name:SURFACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW OFC
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:4607 MACCORKLE AVE SW STE 401
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309
Practice Address - Country:US
Practice Address - Phone:304-414-2120
Practice Address - Fax:304-414-2127
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1585207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0098501000Medicaid
WVBS3879787OtherDEA
WV0098501000Medicaid
WV5403476OtherAETNA
WVBS3879787OtherDEA
WVPOO115425OtherRAILROAD MEDICARE
WV0827735Medicare PIN