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 | 207Q00000X | Family Medicine | | 13834 | 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 | 505821 | OTHER | WEST VIRGINIA | NATIONAL CAPITAL PPO |
| 2 | B59751 | OTHER | WEST VIRGINIA | CARELINK |
| 3 | B59751 | OTHER | WEST VIRGINIA | WV WORKER'S COMP |
| 4 | 0573010 | OTHER | WEST VIRGINIA | HOME PLAN PEIA AND CHIPS |
| 5 | 0004420425 | OTHER | WEST VIRGINIA | AETNA |
| 6 | 080057483 | OTHER | WEST VIRGINIA | RR MEDICARE |
| 7 | FQ13834 | OTHER | WEST VIRGINIA | HEALTH PLAN |
| 8 | B59751 | MEDICARE UPIN | WEST VIRGINIA | |
| 9 | 0050765000 | MEDICAID | WEST VIRGINIA | |
| 10 | 000514416 | OTHER | WEST VIRGINIA | MT STATE BC/BS |
| 11 | 1649202060 | OTHER | WEST VIRGINIA | OHIO WORKER'S COMP |
| 12 | 550486849 0013 | OTHER | WEST VIRGINIA | CIGNA |
| 13 | SC0647221 | MEDICARE PIN | WEST VIRGINIA | |
