Healthcare Provider Details

I. General information

NPI: 1336302058
Provider Name (Legal Business Name): TODD ASHLEY MAGES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 LOCUST AVE
FAIRMONT WV
26554-1435
US

IV. Provider business mailing address

209 BLUE RIDGE LN
MORGANTOWN WV
26508
US

V. Phone/Fax

Practice location:
  • Phone: 304-367-7100
  • Fax:
Mailing address:
  • Phone: 305-978-4751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number064858
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number53216020
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24759
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: