Basic Information
| Provider Information | |||||||||
| NPI: | 1073256665 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY PHYSICIANS & SURGEONS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1448 10TH AVE STE 304 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046918714 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1080 MEADOWBROOK LN | ||||||||
| Address2: | |||||||||
| City: | LOUISA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 412309657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066384389 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2022 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STRAUB | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | MATTHEW | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3046911600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY PHYSICIANS & SURGEONS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker | 174H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Health Educator | 171400000X | Y | 193200000X MULTI-SPECIALTY GROUP |
No ID Information.