Healthcare Provider Details

I. General information

NPI: 1063739944
Provider Name (Legal Business Name): ROBERT MYLES AUSTIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

IV. Provider business mailing address

PO BOX 1547
CHARLESTON WV
25326-1547
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7170
  • Fax: 304-388-1858
Mailing address:
  • Phone: 304-388-7170
  • Fax: 304-388-1858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2623
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: