Healthcare Provider Details

I. General information

NPI: 1114124799
Provider Name (Legal Business Name): PULMONARY ASSOCIATES OF CHAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4619 KANAWHA AVE., SW
SOUTH CHARLESTON WV
25309
US

IV. Provider business mailing address

4619 KANAWHA AVE., SW
SOUTH CHARLESTON WV
25309
US

V. Phone/Fax

Practice location:
  • Phone: 304-400-4545
  • Fax: 304-400-4546
Mailing address:
  • Phone: 304-400-4545
  • Fax: 304-400-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number1828
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN MUSILLI
Title or Position: CFO
Credential:
Phone: 304-400-4545