Healthcare Provider Details

I. General information

NPI: 1942314620
Provider Name (Legal Business Name): DOUGLAS SCOTT TICE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 MEDICAL CT
MARTINSBURG WV
25401-2843
US

IV. Provider business mailing address

309 MEDICAL CT
MARTINSBURG WV
25401-2843
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-0953
  • Fax: 304-263-5826
Mailing address:
  • Phone: 304-263-0953
  • Fax: 304-263-5826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD53001
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number16852
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD066898L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number200400986
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberD53001
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number200400986
License Number StateNC
# 7
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number16852
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: