=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922007186
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KISHOR S PATHAK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 NEW HOPE RD QUAIL VALLEY MEDICAL CENTER NO 7
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24740-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-487-1076
-----------------------------------------------------
Fax | 304-425-9499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 NEW HOPE RD PO BOX 1559
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24740-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-487-1076
-----------------------------------------------------
Fax | 304-425-9499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 11061
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------