Healthcare Provider Details

I. General information

NPI: 1154436004
Provider Name (Legal Business Name): MIDTOWNE FAMILY PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 12TH STREET EXT
PRINCETON WV
24740-2300
US

IV. Provider business mailing address

PO BOX 1030
PRINCETON WV
24740-1030
US

V. Phone/Fax

Practice location:
  • Phone: 304-431-9998
  • Fax: 304-425-0782
Mailing address:
  • Phone: 304-431-7100
  • Fax: 304-431-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1040
License Number StateWV

VIII. Authorized Official

Name: PAMELA P. FAULKNER
Title or Position: PHYSICIAN/OWNER
Credential: DO
Phone: 304-431-7100