Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 208100000X | Physical Medicine & Rehabilitation | | | WEST VIRGINIA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 784081100 | OTHER | MARYLAND | MARYLAND MEDICAID |
| 2 | ========= | OTHER | | CARELINK |
| 3 | 1424801 | OTHER | | UMWA |
| 4 | 198177 | OTHER | | FEDERAL BLACK LUNG |
| 5 | RU9291722 | MEDICARE PIN | WEST VIRGINIA | |
| 6 | CG6938 | OTHER | | RAILROAD MEDICARE |
| 7 | 0016737660001 | OTHER | PENNSYLVANIA | PENNSYLVANIA MEDICAID |
| 8 | 001707270 | OTHER | | MT STATE BLUE CROSS BLUE |
| 9 | =========00 | OTHER | | BRICKSTREET WORK COMP |
| 10 | ========= | OTHER | | CIGNA |
| 11 | ========= | OTHER | | HEALTH ADVANTAGE |
| 12 | =========00 | OTHER | | GATES MCDONALD WORK COMP |
| 13 | ========= | OTHER | | TRICARE CHAMPUS |
