Basic Information
| Provider Information | |||||||||
| NPI: | 1306995626 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VINTON CO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VINTON COUNTY COMMISSIONERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045211576 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 31931 SR 93 NORTH | ||||||||
| Address2: | |||||||||
| City: | MCARTHUR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405964122 | ||||||||
| FaxNumber: | 7405963718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 02/13/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3045211576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic | 341600000X | 020972950 | OH | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 000000155265 | 01 | OH | BLUE CROSS BLUE SHIELD | OTHER | 2029923 | 05 | OH | MEDICAID |