Healthcare Provider Details

I. General information

NPI: 1144329707
Provider Name (Legal Business Name): MARY CAROLINE MIKOWSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RT 50 WEST
SALEM WV
26426
US

IV. Provider business mailing address

PO BOX 392
SALEM WV
26426-0392
US

V. Phone/Fax

Practice location:
  • Phone: 304-782-2000
  • Fax: 304-782-3102
Mailing address:
  • Phone: 304-782-2000
  • Fax: 304-782-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17990
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: