Healthcare Provider Details

I. General information

NPI: 1356333405
Provider Name (Legal Business Name): LAWRENCE BLAIR THRUSH JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411A NOYES AVE SE
CHARLESTON WV
25304
US

IV. Provider business mailing address

3411A NOYES AVE SE
CHARLESTON WV
25304
US

V. Phone/Fax

Practice location:
  • Phone: 304-344-2459
  • Fax: 304-345-1336
Mailing address:
  • Phone: 304-344-2459
  • Fax: 304-345-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number11974
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number11974
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: