Healthcare Provider Details

I. General information

NPI: 1710769328
Provider Name (Legal Business Name): MAGDELINE LIDDON PRSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MEDICAL CENTER DRIVE
HUNTINGTON WV
25701-3656
US

IV. Provider business mailing address

1448 10TH AVENUE SUITE 304
HUNTINGTON WV
25701-3579
US

V. Phone/Fax

Practice location:
  • Phone: 304-696-8700
  • Fax: 304-696-8701
Mailing address:
  • Phone: 304-691-6381
  • Fax: 304-691-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number21-9132
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: