Basic Information
| Provider Information | |||||||||
| NPI: | 1396722641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW CENTURY EMERGENCY PHYSICIAN 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253023351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043882550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 09/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8007263627 | ||||||||
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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 | 363L00000X | WV | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | WV | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | WV | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001769857 | 01 | WV | WV BCBS (PA) | OTHER | 001965204 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 0203138000 | 05 | WV | MEDICAID | 3048964 | 05 | OH | MEDICAID | 001709240 | 01 | WV | WV BCBS (NP) | OTHER | 001709239 | 01 | WV | WV BCBS (MD DO) | OTHER | 0203048000 | 05 | WV | MEDICAID | 001965433 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 150778001 | 01 | WV | DEPARTMENT OF LABOR | OTHER | 001965430 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER |