Healthcare Provider Details

I. General information

NPI: 1124714548
Provider Name (Legal Business Name): ROBERT J STAWICKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5432
  • Fax:
Mailing address:
  • Phone: 304-388-4172
  • Fax: 304-388-4155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4673
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: