MEDICARE: HAVEN N WALL JR MD INC

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	207RC0000X	Cardiovascular Disease Physician	12141	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710013081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN N WALL JR MD INC

Provider Business Mailing Address
First Line	:	PO BOX 1046
Second Line	:
City	:	LEWISBURG
State	:	WV
Zip	:	24901-4046
Country	:	US
Telephone Number	:	304-645-6083
Fax Number	:

Provider Business Practice Location Address
First Line	:	RR 2 BOX 171C
Second Line	:
City	:	LEWISBURG
State	:	WV
Zip	:	24901-9318
Country	:	US
Telephone Number	:	304-645-6083
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HAVEN N WALL
Credential	:	MD
Telephone Number	:	304-645-6083

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	05/14/2010

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