Healthcare Provider Details

I. General information

NPI: 1639408495
Provider Name (Legal Business Name): PRESTON MEMORIAL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12302 VETERAN'S MEMORIAL HIGHWAY
REEDSVILLE WV
26547
US

IV. Provider business mailing address

300 S PRICE ST
KINGWOOD WV
26537-1442
US

V. Phone/Fax

Practice location:
  • Phone: 304-864-7393
  • Fax: 304-864-2827
Mailing address:
  • Phone: 304-329-1400
  • Fax: 304-329-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateWV

VIII. Authorized Official

Name: MRS. MELISSA LOCKWOOD
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 304-329-1400