MEDICARE: MBH PHYSICIAN GROUP -WV PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy

General Provider Information

NPI Number	:	1265951271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MBH PHYSICIAN GROUP -WV PLLC

Provider Business Mailing Address
First Line	:	1014 CEDARWOOD CIR
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29501-8497
Country	:	US
Telephone Number	:	843-687-4329
Fax Number	:

Provider Business Practice Location Address
First Line	:	1418 MACCORKLE AVE SW
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25303-1342
Country	:	US
Telephone Number	:	304-925-6914
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CYNTHIA PERSILY
Credential	:
Telephone Number	:	304-348-1421

Provider Enumeration Date	:	09/12/2017
Last Update Date	:	09/12/2017

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