=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902095912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALBERT V JELLEN INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2007
-----------------------------------------------------
Last Update Date | 03/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2097 NATIONAL RD
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26003-5240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-242-5151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2097 NATIONAL RD
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26003-5240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-242-5151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ALBERT V JELLEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-242-5151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 10293
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------