Healthcare Provider Details

I. General information

NPI: 1659359396
Provider Name (Legal Business Name): THOMAS BAILEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 PHILPOTT LN
BEAVER WV
25813-9501
US

IV. Provider business mailing address

175 PHILPOTT LN
BEAVER WV
25813-9501
US

V. Phone/Fax

Practice location:
  • Phone: 304-254-9262
  • Fax:
Mailing address:
  • Phone: 304-254-9262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number17538
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: