Provider Demographics
NPI:1871782250
Name:KELLY M PITSENBARGER MD
Entity type:Organization
Organization Name:KELLY M PITSENBARGER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:PITSENBARGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-255-2426
Mailing Address - Street 1:314 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:314 GEORGE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2653
Practice Address - Country:US
Practice Address - Phone:304-255-2426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0057171000Medicaid
WVA72419Medicare UPIN
WV0057171000Medicaid