Provider Demographics
NPI:1396766051
Name:SALON, ELY JEAN (MD)
Entity type:Individual
Prefix:
First Name:ELY
Middle Name:JEAN
Last Name:SALON
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 1:252 RURAL ACRES DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3503
Mailing Address - Country:US
Mailing Address - Phone:304-252-8324
Mailing Address - Fax:304-252-7372
Practice Address - Street 1:200 RALEIGH AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-5989
Practice Address - Country:US
Practice Address - Phone:304-252-8541
Practice Address - Fax:304-253-2507
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18381207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001722335OtherBLUE CROSS BLUE SHIELD
WV2032422OtherMEDICATE PTAN
WV0079492000Medicaid
WV0812202Medicare PIN
WV0079492000Medicaid