Healthcare Provider Details

I. General information

NPI: 1174582456
Provider Name (Legal Business Name): JACK R TRAYLOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HAL GREER BOULEVARD
HUNTINGTON WV
25701-3656
US

IV. Provider business mailing address

1400 HAL GREER BOULEVARD
HUNTINGTON WV
25701-3656
US

V. Phone/Fax

Practice location:
  • Phone: 304-399-6609
  • Fax: 304-399-6621
Mailing address:
  • Phone: 304-399-6556
  • Fax: 304-399-6554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number12969
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: