Basic Information
| Provider Information | |||||||||
| NPI: | 1588916399 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WV ASTHMA AND ALLERGY CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASTHMA AND ALLERGY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253141160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434300 | ||||||||
| FaxNumber: | 3043435473 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 6TH AVE | ||||||||
| Address2: | SUITE 303D | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251362116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434300 | ||||||||
| FaxNumber: | 3043435473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2012 | ||||||||
| LastUpdateDate: | 10/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | MATHENA | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3043434300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 78687 | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 0006123000 | 05 | WV | MEDICAID |