Healthcare Provider Details

I. General information

NPI: 1982274965
Provider Name (Legal Business Name): MED SURG PHYSICIAN GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 08/20/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MARTIN DR
MOUNT HOPE WV
25880-1509
US

IV. Provider business mailing address

379 STANAFORD RD
BECKLEY WV
25801-3141
US

V. Phone/Fax

Practice location:
  • Phone: 304-253-3000
  • Fax: 304-929-2038
Mailing address:
  • Phone: 304-253-3000
  • Fax: 304-929-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: OLU R SANGODEYI
Title or Position: PRESIDENT, PHYSICIAN
Credential: MD, CEO
Phone: 304-253-3000