MEDICARE: SOUTH CHARLESTON PRIMARY CARE ASSOCIATES

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	207Q00000X	Family Medicine Physician	10611	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

General Provider Information

NPI Number	:	1457449761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH CHARLESTON PRIMARY CARE ASSOCIATES

Provider Business Mailing Address
First Line	:	312 6TH AVE
Second Line	:	SUITE 3
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25303-1242
Country	:	US
Telephone Number	:	304-744-4532
Fax Number	:	304-744-3219

Provider Business Practice Location Address
First Line	:	312 6TH AVE
Second Line	:	SUITE 3
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25303-1242
Country	:	US
Telephone Number	:	304-744-4532
Fax Number	:	304-744-3219

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	TAMMY SUE KING
Credential	:
Telephone Number	:	304-744-4532

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	11/11/2013

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Directions to “SOUTH CHARLESTON PRIMARY CARE ASSOCIATES ” Practice Location

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