Basic Information
| Provider Information | |||||||||
| NPI: | 1134230311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDANIEL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ELLIOTT | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4190 | ||||||||
| Address2: | |||||||||
| City: | BARBOURSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255044190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043994405 | ||||||||
| FaxNumber: | 3043992526 | ||||||||
| Practice Location | |||||||||
| Address1: | 2827 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043997182 | ||||||||
| FaxNumber: | 3045237738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS10096 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 34.010454 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2012-01177 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 1980 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30257 | 05 | FL | MEDICAID | P01135827 | 01 | OH | MEDICARE RAILROAD - MHCPI | OTHER | P00609571 | 01 | FL | MCR RR | OTHER | 0066990 | 05 | OH | MEDICAID | 2004366000 | 05 | OH | MEDICAID |