MEDICARE: CHARLESTON FAMILY PRACTICE GROUP

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	11909	WV

General Provider Information

NPI Number	:	1750310280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLESTON FAMILY PRACTICE GROUP

Provider Business Mailing Address
First Line	:	1220 LEE ST E STE 201
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-1864
Country	:	US
Telephone Number	:	304-342-8513
Fax Number	:	304-342-8147

Provider Business Practice Location Address
First Line	:	1220 LEE ST E STE 201
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-1864
Country	:	US
Telephone Number	:	304-342-8513
Fax Number	:	304-342-8147

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MALCOLM L. CHANEY
Credential	:	M.D.
Telephone Number	:	304-342-8513

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	02/27/2020

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Directions to “CHARLESTON FAMILY PRACTICE GROUP ” Practice Location

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