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General NPI Number Information
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NPI Number | 1497803878
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Entity Type | Individual
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Provider Name | THOMAS GEORGE WACK JR. MD
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Gender | Male
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 10/09/2012
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Provider Practice Location Address
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Address Line | 616 FAIRMONT PIKE RT 88
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City | WHEELING
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State | WV
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Zip | 26003
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Country | US
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Telephone | 304-242-3550
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Fax | 304-242-5810
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Provider Business Mailing Address
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Address Line | 616 FAIRMONT PIKE RT 88 PO BOX 2286
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City | WHEELING
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State | WV
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Zip | 26003
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Country | US
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Telephone | 304-242-3550
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Fax | 304-242-5810
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 11364
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License Number State | WV
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