Healthcare Provider Details

I. General information

NPI: 1124477138
Provider Name (Legal Business Name): MELISSA RENA KIJEWSKI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1563 SAND PLANT RD
SOUTH CHARLESTON WV
25309-6120
US

IV. Provider business mailing address

3200 MACCORKLE AVE. SE, CAMC FAMILY MEDICINE CENTER ROBERT C. BYRD CLINICAL TEACHING CENTER
CHARLESTON WV
25304
US

V. Phone/Fax

Practice location:
  • Phone: 304-756-1500
  • Fax: 304-756-1548
Mailing address:
  • Phone: 304-388-4600
  • Fax: 304-388-4621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3320
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: