Provider Demographics
NPI:1982764908
Name:BECKLEY AREA MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:BECKLEY AREA MEDICAL CLINIC, INC
Other - Org Name:SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIAL SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-237-9107
Mailing Address - Street 1:1828 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3366
Mailing Address - Country:US
Mailing Address - Phone:304-253-5690
Mailing Address - Fax:304-255-4608
Practice Address - Street 1:1828 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3366
Practice Address - Country:US
Practice Address - Phone:304-253-5690
Practice Address - Fax:304-255-4608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11126174400000X
WV10539174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0010538-000Medicaid
WV0010538-000Medicaid