Healthcare Provider Details

I. General information

NPI: 1134174212
Provider Name (Legal Business Name): STEPHEN KARL RERYCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 VALLEY DR
PT PLEASANT WV
25550-2031
US

IV. Provider business mailing address

PO BOX 236
PT PLEASANT WV
25550-0236
US

V. Phone/Fax

Practice location:
  • Phone: 304-675-1666
  • Fax: 304-675-2944
Mailing address:
  • Phone: 304-675-1666
  • Fax: 304-675-5893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number22335
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: