Healthcare Provider Details

I. General information

NPI: 1023004744
Provider Name (Legal Business Name): KELLY MCCOY PITSENBARGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 CARPENTER ST
SHADY SPRING WV
25918-8417
US

IV. Provider business mailing address

PO BOX 1437
SHADY SPRING WV
25918-1437
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-2426
  • Fax: 304-253-3715
Mailing address:
  • Phone: 304-255-2426
  • Fax: 304-253-3715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberWV13927
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: