MEDICARE: DR. STEPHANUS JOHANNES SERFONTEIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	21778	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154420990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHANUS JOHANNES SERFONTEIN MD

Provider Business Mailing Address
First Line	:	3200 MACCORKLE SEAVE B16
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-1227
Country	:	US
Telephone Number	:	304-388-5848
Fax Number	:	304-388-9654

Provider Business Practice Location Address
First Line	:	2418 JEFFERSON AVE
Second Line	:
City	:	PT PLEASANT
State	:	WV
Zip	:	25550-1528
Country	:	US
Telephone Number	:	304-675-6835
Fax Number	:	304-675-6849

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	12/22/2015

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