Provider Demographics
NPI:1205920261
Name:TIERNEY, JAMES P (DO)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:TIERNEY
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 1:11 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2699
Mailing Address - Country:US
Mailing Address - Phone:304-925-8521
Mailing Address - Fax:304-925-8523
Practice Address - Street 1:11 COURTNEY DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-925-8521
Practice Address - Fax:304-925-8523
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV775208800000X
WVOT0296775208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0129896000Medicaid
WV0129896000Medicaid
TI4257561Medicare PIN
TI0601782Medicare PIN
WV0601782Medicare ID - Type Unspecified
B42716Medicare UPIN