Healthcare Provider Details

I. General information

NPI: 1730151010
Provider Name (Legal Business Name): ALICE JODY ACKERMAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HEALTHCARE DR MANSFIELD HILL
PHILIPPI WV
26416
US

IV. Provider business mailing address

1 HEALTHCARE DR MANSFIELD HILL
PHILIPPI WV
26416-9405
US

V. Phone/Fax

Practice location:
  • Phone: 304-457-1760
  • Fax: 304-457-3781
Mailing address:
  • Phone: 304-457-1760
  • Fax: 304-457-3781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2159
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2159
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05-009868-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: