=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427165869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J. TODD DOUGLAS, MD, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 01/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 E OHIO ST
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42261-7944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-526-2772
-----------------------------------------------------
Fax | 270-526-6323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1367 205 EAST OHIO ST
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42261-1367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-526-2772
-----------------------------------------------------
Fax | 270-526-6323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. JAMES TODD DOUGLAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 270-526-2772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 7100116510
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 34188
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------