Basic Information
| Provider Information | |||||||||
| NPI: | 1063519445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANTT | ||||||||
| FirstName: | PICKENS | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 PENNSYLVANIA AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043882863 | ||||||||
| FaxNumber: | 3043882866 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 PENNSYLVANIA AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253023302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043882863 | ||||||||
| FaxNumber: | 3043882866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 13100 | TN | N | Other Service Providers | Specialist | 207VE0102X | 22945 | WV | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 3810010685 | 05 | WV | MEDICAID |