Basic Information
| Provider Information | |||||||||
| NPI: | 1316928344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELWOOD | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | ELEANOR | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250700503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045860001 | ||||||||
| FaxNumber: | 3045861301 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 ROOSEVELT BLVD. | ||||||||
| Address2: | |||||||||
| City: | ELEANOR | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045860001 | ||||||||
| FaxNumber: | 3045861301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 053140 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 23395 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1316928344 | 05 | WV | MEDICAID | WV0542A | 01 | WV | MEDICARE PIN | OTHER |