Basic Information
| Provider Information | |||||||||
| NPI: | 1114959202 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OTTAVIANO | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1249 15TH ST | ||||||||
| Address2: | SUITE 3000 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911000 | ||||||||
| FaxNumber: | 3046911693 | ||||||||
| Practice Location | |||||||||
| Address1: | 1249 15TH ST | ||||||||
| Address2: | SUITE 3000 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911000 | ||||||||
| FaxNumber: | 3046911693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 11/06/2012 | ||||||||
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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 | 207RP1001X | 1144 | WV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 0042458000 | 05 | WV | MEDICAID | 6407504 | 05 | KY | MEDICAID | 0917128 | 05 | OH | MEDICAID | 290005124 | 01 | RAILROAD MEDICARE | OTHER |