=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265951271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MBH PHYSICIAN GROUP -WV PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2017
-----------------------------------------------------
Last Update Date | 09/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1418 MACCORKLE AVE SW
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25303-1342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-925-6914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 CEDARWOOD CIR
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29501-8497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-687-4329
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CYNTHIA PERSILY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-348-1421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------