=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619973096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL M BOUSTANY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2005
-----------------------------------------------------
Last Update Date | 12/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 434 DIVISION ST
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-766-7140
-----------------------------------------------------
Fax | 304-766-7180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4605 MACCORKLE AVE SW
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-414-4800
-----------------------------------------------------
Fax | 304-414-4801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | 10600
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 10600
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------