Basic Information
| Provider Information | |||||||||
| NPI: | 1215946223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | LAWRENCE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 ROCK RUN RD. | ||||||||
| Address2: | |||||||||
| City: | FRIENDLY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135633332 | ||||||||
| FaxNumber: | 3135633342 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 ROCK RUN RD. | ||||||||
| Address2: | |||||||||
| City: | FRIENDLY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135633332 | ||||||||
| FaxNumber: | 3135633342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 12/07/2010 | ||||||||
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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 | 207R00000X | 5101009765 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.