Healthcare Provider Details

I. General information

NPI: 1598718074
Provider Name (Legal Business Name): MED EX PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 WASHINGTON ST
RAVENSWOOD WV
26164-1729
US

IV. Provider business mailing address

705 WASHINGTON ST
RAVENSWOOD WV
26164-1729
US

V. Phone/Fax

Practice location:
  • Phone: 800-824-2543
  • Fax: 330-862-2356
Mailing address:
  • Phone: 800-824-2543
  • Fax: 330-862-2356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD J. BLACKBURN
Title or Position: PRESIDENT
Credential: DO
Phone: 800-824-2543