Healthcare Provider Details

I. General information

NPI: 1598786592
Provider Name (Legal Business Name): ROLAND F CHALIFOUX JR DO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W BALTIMORE ST
MCMECHEN WV
26040-1503
US

IV. Provider business mailing address

1001 W BALTIMORE ST
MCMECHEN WV
26040-1503
US

V. Phone/Fax

Practice location:
  • Phone: 304-242-4004
  • Fax: 304-242-8004
Mailing address:
  • Phone: 304-242-4004
  • Fax: 304-242-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2077
License Number StateWV

VIII. Authorized Official

Name: ROLAND F CHALIFOUX JR
Title or Position: OWNER
Credential: DO
Phone: 304-242-4004