Healthcare Provider Details

I. General information

NPI: 1689057101
Provider Name (Legal Business Name): RADHIKA GHOSH M.B.B.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PENNSYLVANIA AVE STE 103
CHARLESTON WV
25302-3389
US

IV. Provider business mailing address

830 PENNSYLVANIA AVE STE 103
CHARLESTON WV
25302-3389
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-1552
  • Fax: 304-388-1565
Mailing address:
  • Phone: 304-388-1552
  • Fax: 304-388-1565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number295705
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number82944
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number31143
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: