Healthcare Provider Details

I. General information

NPI: 1235259938
Provider Name (Legal Business Name): PINEVIEW DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 PINEVIEW DR SUITE 200
MORGANTOWN WV
26505-3276
US

IV. Provider business mailing address

1311 PINEVIEW DR SUITE 200
MORGANTOWN WV
26505-3276
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-7546
  • Fax: 304-225-7551
Mailing address:
  • Phone: 304-598-7546
  • Fax: 304-225-7551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number17968
License Number StateWV

VIII. Authorized Official

Name: DR. KENNETH F HARDY JR.
Title or Position: CEO
Credential: M.D.
Phone: 304-598-7546