Healthcare Provider Details

I. General information

NPI: 1790116341
Provider Name (Legal Business Name): ASSOCIATED SPECIALISTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 MEDICAL PARK DR STE 204
BRIDGEPORT WV
26330-9009
US

IV. Provider business mailing address

527 MEDICAL PARK DR STE 204
BRIDGEPORT WV
26330-9009
US

V. Phone/Fax

Practice location:
  • Phone: 304-933-3800
  • Fax: 304-933-3815
Mailing address:
  • Phone: 304-933-3800
  • Fax: 304-933-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number55-0532650
License Number StateWV

VIII. Authorized Official

Name: MS. LORI LEE POWELL
Title or Position: OFFICE MANAGER
Credential: RHIT
Phone: 304-933-3800