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General NPI Number Information
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NPI Number | 1730378928
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Entity Type | Organization
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Legal Business Name | CRAB ORCHARD MEDICAL ASSOC. INC.
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Dates
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Enumeration Date | 10/24/2007
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Last Update Date | 10/24/2007
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Provider Practice Location Address
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Address Line | 1701 ROBERT C. BYRD DRIVE
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City | CRAB ORCHARD
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State | WV
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Zip | 25827
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Country | US
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Telephone | 304-253-8336
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Fax | 304-253-8337
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Provider Business Mailing Address
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Address Line | PO BOX 1602
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City | CRAB ORCHARD
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State | WV
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Zip | 25827-1602
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Country | US
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Telephone | 304-253-8336
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Fax | 304-253-8336
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MARIZA A. LIRIO
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Credential | M.D.
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Telephone | 304-253-8336
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 12066
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License Number State | WV
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