Healthcare Provider Details

I. General information

NPI: 1356579163
Provider Name (Legal Business Name): NICK TREADWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 VETERANS AVE
BECKLEY WV
25801-6444
US

IV. Provider business mailing address

200 VETERANS AVE
BECKLEY WV
25801-6444
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-2121
  • Fax:
Mailing address:
  • Phone: 304-255-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number24339
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: