Basic Information
| Provider Information | |||||||||
| NPI: | 1366446015 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE MYERS CLINIC, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE MYERS CLINIC, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 900 | ||||||||
| Address2: | # 3 HEALTH CARE DRIVE | ||||||||
| City: | PHILIPPI | ||||||||
| State: | WV | ||||||||
| PostalCode: | 264160900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044572800 | ||||||||
| FaxNumber: | 3044574011 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 HEALTH CARE DRIVE | ||||||||
| Address2: | |||||||||
| City: | PHILIPPI | ||||||||
| State: | WV | ||||||||
| PostalCode: | 264160900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044572800 | ||||||||
| FaxNumber: | 3044574011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3044572800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BELINGTON COMMUNITY MEDICAL SERVICES ASSOCIATION, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0315003000 | 05 | WV | MEDICAID | DE1820 | 01 | WV | RAILROAD MEDICARE | OTHER |