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 | 332B00000X | Durable Medical Equipment & Medical Supplies | | 770649 | WEST VIRGINIA | No |
| 2 | 332B00000X | Durable Medical Equipment & Medical Supplies | | CONTROLNUMBER72117 | 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 | 001704877 | OTHER | WEST VIRGINIA | BLUE CROSS BLUE SHIELD |
| 2 | 407251100 | MEDICAID | MARYLAND | |
| 3 | 3810001835 | MEDICAID | WEST VIRGINIA | |
| 4 | DME315 | OTHER | WEST VIRGINIA | HEALTH PLAN PROVIDER # |
| 5 | 101294177 0001 | MEDICAID | PENNSYLVANIA | |
