Provider Demographics
NPI:1184617003
Name:BARBOURSVILLE INTERNAL MEDICINE & PEDIATRICS
Entity type:Organization
Organization Name:BARBOURSVILLE INTERNAL MEDICINE & PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-736-4000
Mailing Address - Street 1:4 CHATEAU LN
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1626
Mailing Address - Country:US
Mailing Address - Phone:304-736-4000
Mailing Address - Fax:304-736-5690
Practice Address - Street 1:4 CHATEAU LN
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1626
Practice Address - Country:US
Practice Address - Phone:304-736-4000
Practice Address - Fax:304-736-5690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2204877Medicaid
WV0201059000Medicaid
BA9311131Medicare ID - Type Unspecified