Basic Information
| Provider Information | |||||||||
| NPI: | 1033206263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLESTON INTERNAL MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047202345 | ||||||||
| FaxNumber: | 3047202347 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047202345 | ||||||||
| FaxNumber: | 3047202347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | BOWDEN | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3047202345 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810004289 | 05 | WV | MEDICAID |