Healthcare Provider Details

I. General information

NPI: 1659585263
Provider Name (Legal Business Name): WHITEHALL MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 ROXBURY ROAD
WHITE HALL WV
26554-3430
US

IV. Provider business mailing address

60 ROXBURY ROAD
WHITE HALL WV
26554-3430
US

V. Phone/Fax

Practice location:
  • Phone: 304-363-6600
  • Fax: 304-363-7700
Mailing address:
  • Phone: 304-363-6600
  • Fax: 304-363-7700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5100942930
License Number StateWV

VIII. Authorized Official

Name: DR. RICHARD E VASICEK
Title or Position: MEMBER SINGLE OWNER
Credential:
Phone: 304-363-6600