=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821058348
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL TIMOTHY KURYLA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2006
-----------------------------------------------------
Last Update Date | 12/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 DIVISION ST STE 6
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309-1459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-414-4863
-----------------------------------------------------
Fax | 304-414-4864
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
=====================================================
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 | 15514
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------