Healthcare Provider Details

I. General information

NPI: 1023017027
Provider Name (Legal Business Name): JOHN G. STANSBURY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 11/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HUNT CLUB PLZ
RIDGELEY WV
26753-5213
US

IV. Provider business mailing address

11 HUNT CLUB PLZ
RIDGELEY WV
26753-5213
US

V. Phone/Fax

Practice location:
  • Phone: 304-726-4501
  • Fax: 304-726-4051
Mailing address:
  • Phone: 304-726-4501
  • Fax: 304-726-4051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberD23765
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number15011
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: