Basic Information
| Provider Information | |||||||||
| NPI: | 1104996776 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RICHARD T.C. WAN, M.D. ,PSC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WAN'S MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 129 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422610129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705263841 | ||||||||
| FaxNumber: | 2705262651 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W ROBERTS ST | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422617942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705263841 | ||||||||
| FaxNumber: | 2705262651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | TC | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2705263841 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 16599 | KY | Y | Managed Care Organizations | Preferred Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 65902033 | 05 | KY | MEDICAID | 18DO326142 | 01 | KY | CLIA | OTHER | 000000045886 | 01 | KY | BCBS | OTHER |