Healthcare Provider Details

I. General information

NPI: 1801822242
Provider Name (Legal Business Name): TULLY STEPHEN ROISMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 HAL GREER BLVD
HUNTINGTON WV
25701-3705
US

IV. Provider business mailing address

1151 HAL GREER BLVD
HUNTINGTON WV
25701-3705
US

V. Phone/Fax

Practice location:
  • Phone: 304-529-2800
  • Fax: 304-529-2802
Mailing address:
  • Phone: 304-529-2800
  • Fax: 304-529-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number12735
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number23615
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: