Provider Demographics
NPI:1255403002
Name:APPALACHIAN HIGHWAY MEDICAL & SURGICAL CLINIC, PLLC
Entity type:Organization
Organization Name:APPALACHIAN HIGHWAY MEDICAL & SURGICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINADOR
Authorized Official - Middle Name:YTI
Authorized Official - Last Name:LAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-732-9045
Mailing Address - Street 1:APPALACHIAN HIGHWAY RT. 10 EAST PINEVILLE
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:24874-1274
Mailing Address - Country:US
Mailing Address - Phone:304-732-9045
Mailing Address - Fax:304-732-9055
Practice Address - Street 1:APPALACHIAN HWY, RT. 10 EAST PINEVILLE
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874-1274
Practice Address - Country:US
Practice Address - Phone:304-732-9045
Practice Address - Fax:304-732-9055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12700261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV200001780OtherRAILROAD MEDICARE
WV00182204OtherBLUE CROSS BLUE SHIELD
WV0128304001Medicaid
WV57799OtherUNICARE
WV1220372OtherCHA
WV9364951Medicare PIN
WV00182204OtherBLUE CROSS BLUE SHIELD