Healthcare Provider Details

I. General information

NPI: 1326064486
Provider Name (Legal Business Name): FRED PATRICK TZYSTUCK II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 HARPER RD
BECKLEY WV
25801-3357
US

IV. Provider business mailing address

PO BOX 634715
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 304-254-3101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number21661
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: