Basic Information
Provider Information | |||||||||
NPI: | 1417901299 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLE | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
Address2: |   | ||||||||
City: | KETTERING | ||||||||
State: | OH | ||||||||
PostalCode: | 454295164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8008750136 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 NORTH AVE | ||||||||
Address2: |   | ||||||||
City: | BATTLE CREEK | ||||||||
State: | MI | ||||||||
PostalCode: | 490173307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2699668000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 09/23/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 20318 | WV | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 010275580 | 01 | WV | VA MCD | OTHER | 3001521 | 01 | WV | WV DWC | OTHER | 001807945 | 01 | WV | WV BC/BS | OTHER | 3810004990 | 05 | WV |   | MEDICAID |