Healthcare Provider Details

I. General information

NPI: 1952448532
Provider Name (Legal Business Name): MYRA D. PRIDDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 FAIRVIEW HEIGHTS RD
SUMMERSVILLE WV
26651-1086
US

IV. Provider business mailing address

127 HIDDEN VALLEY ESTS
SCOTT DEPOT WV
25560-9300
US

V. Phone/Fax

Practice location:
  • Phone: 304-872-5213
  • Fax: 304-872-5893
Mailing address:
  • Phone: 304-253-9355
  • Fax: 304-253-0018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19575
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19575
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: