Provider Demographics
NPI:1770558165
Name:CHARLESTON CARDIOLOGY GROUP PLLC
Entity type:Organization
Organization Name:CHARLESTON CARDIOLOGY GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN BOARD OF DIRECTORS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-342-1184
Mailing Address - Street 1:3100 MACCORKLE AVE
Mailing Address - Street 2:SUITE 709
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1223
Mailing Address - Country:US
Mailing Address - Phone:304-342-1184
Mailing Address - Fax:304-343-8487
Practice Address - Street 1:3100 MACCORKLE AVE
Practice Address - Street 2:SUITE 709
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1223
Practice Address - Country:US
Practice Address - Phone:304-342-1184
Practice Address - Fax:304-343-8487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004453Medicaid
WV9277671Medicare ID - Type Unspecified