Basic Information
| Provider Information | |||||||||
| NPI: | 1386623783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW CENTURY MEDICAL OBSERVATION SERVICES OF WEST VIRGINIA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194366 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043884170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8008750136 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 150778001 | 01 | WV | FEDERAL BLACK LUNG | OTHER | 610274000 | 01 | WV | FECA | OTHER | 610274000 | 01 | WV | ENERGY | OTHER | 7009670 | 01 | WV | AETNA | OTHER | 001762398 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 150778001 | 01 | WV | FECA | OTHER | 3810003355 | 05 | WV | MEDICAID | 610274000 | 01 | WV | BLACK LUNG | OTHER |