Healthcare Provider Details

I. General information

NPI: 1790947000
Provider Name (Legal Business Name): GAVIN NEIL HOGUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 PATRICK ST
CHARLESTON WV
25312
US

IV. Provider business mailing address

102 PATRICK ST
CHARLESTON WV
25312
US

V. Phone/Fax

Practice location:
  • Phone: 304-346-8213
  • Fax: 304-346-8214
Mailing address:
  • Phone: 304-346-8213
  • Fax: 304-346-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number15029
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: