Healthcare Provider Details

I. General information

NPI: 1447313564
Provider Name (Legal Business Name): FOOTWISE PODIATRY OF W.VA. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1191 PINEVIEW DR STE H1
MORGANTOWN WV
26505-0480
US

IV. Provider business mailing address

1191 PINEVIEW DR STE H1
MORGANTOWN WV
26505-0480
US

V. Phone/Fax

Practice location:
  • Phone: 304-599-9000
  • Fax: 304-599-4091
Mailing address:
  • Phone: 304-599-9000
  • Fax: 304-599-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number193400000X
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. GORDON A MILLER
Title or Position: PRESIDENT PHYSICIAN
Credential: D.P.M.
Phone: 304-599-9000