Healthcare Provider Details

I. General information

NPI: 1801815733
Provider Name (Legal Business Name): MEDICAL ASSOCIATES OF GLEN DANIEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BOLT ROAD
GLEN DANIEL WV
25844
US

IV. Provider business mailing address

310 GEORGE ST
BECKLEY WV
25801-2653
US

V. Phone/Fax

Practice location:
  • Phone: 304-934-5125
  • Fax:
Mailing address:
  • Phone: 304-254-9022
  • Fax: 304-254-9024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberPENDING
License Number StateWV

VIII. Authorized Official

Name: DR. JOSE JORGE GORDINHO
Title or Position: PRESIDENT
Credential: MD
Phone: 304-254-9022