Provider Demographics
NPI:1669583589
Name:CENTRAL WV DERM ASSOC INC
Entity type:Organization
Organization Name:CENTRAL WV DERM ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:304-842-3494
Mailing Address - Street 1:PO BOX 4550
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-4550
Mailing Address - Country:US
Mailing Address - Phone:304-842-3494
Mailing Address - Fax:304-842-2339
Practice Address - Street 1:170 THOMPSON DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-2608
Practice Address - Country:US
Practice Address - Phone:304-842-3494
Practice Address - Fax:304-842-2339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003851Medicaid
OH2624959Medicaid
PA1019121420001Medicaid
OH2624968Medicaid
PA107701V46Medicare PIN
OH2624968Medicaid
WVDD9600Medicare PIN
OH2624959Medicaid