Full Name | |
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Speciality | Family Medicine |
Location | 94 School Dr, Walton, West Virginia |
Authorized Official Name and Position | Douglas E Bentz (CEO) |
Authorized Official Contact | 3049276200 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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200 Hospital Dr Spencer WV 25276-1050 Ph: (304) 927-4444 | 94 School Dr Walton WV 25286-9774 Ph: (304) 577-6815 |
NPI Number | 1639423411 |
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Provider Enumeration Date | 11/01/2012 |
Last Update Date | 12/12/2013 |
Medicare PECOS PAC ID | 4183527476 |
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Medicare Enrollment ID | O20040710000241 |
Identifier | Type | State | Issuer |
---|---|---|---|
1639423411 | NPI | - | NPPES |
513417 | Other | WV | PTAN |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
207Q00000X | Family Medicine | 74 (West Virginia) | Primary |
Provider Name | Katherine Rose V Tigas |
---|---|
Provider Type | Practitioner - Family Practice |
Provider Identifiers | NPI Number: 1124209994 PECOS PAC ID: 5395928345 Enrollment ID: I20110329000312 |