Basic Information
Provider Information | |||||||||
NPI: | 1174581409 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALBERICO | ||||||||
FirstName: | ANTHONY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 MEDICAL CENTER DR | ||||||||
Address2: | SUITE B500 | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257013656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046911787 | ||||||||
FaxNumber: | 3046918711 | ||||||||
Practice Location | |||||||||
Address1: | 1600 MEDICAL CENTER DR | ||||||||
Address2: | SUITE B500 | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257013656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046911787 | ||||||||
FaxNumber: | 3046918711 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 11/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 0101036507 | VA | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 207T00000X | ME54341 | FL | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 207T00000X | 22931 | WV | Y |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 036528900 | 05 | FL |   | MEDICAID | B07880 | 01 |   | VISTA FLORIDA | OTHER | 08437 | 01 |   | BCBS FL | OTHER | 3810010513 | 05 | WV |   | MEDICAID | 206587 | 01 |   | ARMED FLORIDA PIN #1851 | OTHER |