Healthcare Provider Details

I. General information

NPI: 1114009941
Provider Name (Legal Business Name): PRESTON MEMORIAL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARKET STREET GRAFTON CITY HOSPTIAL
GRAFTON WV
26354
US

IV. Provider business mailing address

300 S PRICE ST
KINGWOOD WV
26537-1442
US

V. Phone/Fax

Practice location:
  • Phone: 304-265-6400
  • Fax:
Mailing address:
  • Phone: 304-329-2830
  • Fax: 304-791-3737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateWV

VIII. Authorized Official

Name: MRS. MELISSA LOCKWOOD
Title or Position: CEO
Credential:
Phone: 304-329-4700