=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598766016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES HENRY STAAB III MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 MEDICAL PARK SUITE 223
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26003-6391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-242-3300
-----------------------------------------------------
Fax | 304-242-8964
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 MEDICAL PARK SUITE 223
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26003-6391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-242-3300
-----------------------------------------------------
Fax | 304-242-8964
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 11194
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------