Basic Information
| Provider Information | |||||||||
| NPI: | 1336295443 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARVIN L WELLS DO PC | ||||||||
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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: | 01/25/2007 | ||||||||
| LastUpdateDate: | 11/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | WELLS | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3135633332 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CE8407 | 01 | MI | RR MEDICARE | OTHER | 110F312140 | 01 | MI | BLUE SHIELD | OTHER |