Healthcare Provider Details

I. General information

NPI: 1215039482
Provider Name (Legal Business Name): JACK CHARLES MARCUM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 HOSPITAL PLAZA
WESTON WV
26452-8558
US

IV. Provider business mailing address

230 HOSPITAL PLAZA
WESTON WV
26452-8558
US

V. Phone/Fax

Practice location:
  • Phone: 304-269-8000
  • Fax: 304-269-8090
Mailing address:
  • Phone: 304-269-8032
  • Fax: 304-269-8090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26817
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: