=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699820415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID A CIAROLLA, MD, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 11/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1228 COUNTRY CLUB RD SUITE 300
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-2369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-363-7990
-----------------------------------------------------
Fax | 304-363-7997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1228 COUNTRY CLUB RD SUITE 300
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-2369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-363-7990
-----------------------------------------------------
Fax | 304-363-7997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID ANTHONY CIAROLLA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-363-7990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | WV17859
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------