Basic Information
| Provider Information | |||||||||
| NPI: | 1386711554 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOOD HEALTH CARE CLINIC PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1307 LAFAYETTE AVENUE | ||||||||
| Address2: | |||||||||
| City: | MOUNDSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260412316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048452500 | ||||||||
| FaxNumber: | 3048452624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 LAFAYETTE AVENUE | ||||||||
| Address2: | |||||||||
| City: | MOUNDSVILLLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260412316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048452500 | ||||||||
| FaxNumber: | 3048452624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | RALPH | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | EMPLOYER | ||||||||
| AuthorizedOfficialTelephone: | 3048452500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 07/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0008910000 | 05 | WV | MEDICAID | 0995071 | 05 | OH | MEDICAID | 0008910001 | 01 | WV | LAB NUMBER | OTHER |