Healthcare Provider Details

I. General information

NPI: 1629899869
Provider Name (Legal Business Name): CAMDEN-CLARK PHYSICIAN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 ANN ST
PARKERSBURG WV
26101-5122
US

IV. Provider business mailing address

PO BOX 843
MORGANTOWN WV
26507-0843
US

V. Phone/Fax

Practice location:
  • Phone: 304-865-5065
  • Fax: 304-865-5066
Mailing address:
  • Phone: 304-285-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: KYLE ANTHONY PIERSON
Title or Position: CFO
Credential:
Phone: 304-424-2202