Basic Information
| Provider Information | |||||||||
| NPI: | 1417904848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMALLRIDGE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 327 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263309006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6813421000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 327 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263309006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6813421000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 58541 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0207026000 | 01 | WV | MEDICAID GROUP | OTHER | 3810005046 | 05 | WV | MEDICAID | P00974070 | 01 | WV | MEDICARE RAILROAD | OTHER | 9333201 | 01 | WV | MEDICARE GROUP | OTHER | 1417904848 | 01 | WV | MT STATE BLUE CROSS & BLUE SHIELD | OTHER |