Basic Information
| Provider Information | |||||||||
| NPI: | 1366431900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANTZ | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1029 | ||||||||
| Address2: | |||||||||
| City: | SUMMERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266510139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048725090 | ||||||||
| FaxNumber: | 3048720636 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 FAIRVIEW HEIGHTS RD | ||||||||
| Address2: | |||||||||
| City: | SUMMERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266511085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048725090 | ||||||||
| FaxNumber: | 3048720636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 15520 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0052343000 | 05 | WV | MEDICAID | 550775750 | 01 | TAX ID | OTHER |