Provider Demographics
NPI:1265440952
Name:JELLEN, ALBERT V (MD)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:V
Last Name:JELLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2097 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-242-5151
Mailing Address - Fax:304-242-0365
Practice Address - Street 1:2097 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-242-5151
Practice Address - Fax:304-242-0365
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0055528000Medicaid
OH0270139Medicaid
OH0270139Medicaid
D49221Medicare UPIN