Healthcare Provider Details

I. General information

NPI: 1609975333
Provider Name (Legal Business Name): PLEASANT VALLEY EMERGENCY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 VALLEY DR
PT PLEASANT WV
25550
US

IV. Provider business mailing address

2520 VALLEY DR
PT PLEASANT WV
25550-2031
US

V. Phone/Fax

Practice location:
  • Phone: 304-675-4340
  • Fax: 304-675-1328
Mailing address:
  • Phone: 304-675-4340
  • Fax: 304-675-1328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number945
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1441
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number905
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number18261
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1102
License Number StateWV

VIII. Authorized Official

Name: ROBIN A PAYNE
Title or Position: CREDENTIALLING SPECIALIST
Credential:
Phone: 304-675-4340