Healthcare Provider Details

I. General information

NPI: 1992760698
Provider Name (Legal Business Name): PAMELA MARTIN PHILLIPS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA L MARTIN M.D.

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 KANAWHA BLVD E
CHARLESTON WV
25301-2400
US

IV. Provider business mailing address

PO BOX 11137
CHARLESTON WV
25339-1137
US

V. Phone/Fax

Practice location:
  • Phone: 304-344-3457
  • Fax: 304-344-3480
Mailing address:
  • Phone: 304-344-3457
  • Fax: 304-344-3480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number19277
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number19277
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: