Basic Information
| Provider Information | |||||||||
| NPI: | 1417990185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAUL | ||||||||
| FirstName: | BEVIN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HICKEY | ||||||||
| OtherFirstName: | BEVIN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 150 DUNCAN RD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249249037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047997400 | ||||||||
| FaxNumber: | 3047992276 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 DUNCAN RD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249249037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047997400 | ||||||||
| FaxNumber: | 3047992276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J1-0002261 | DE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 18287 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT 003136 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1417990185 | 01 | DE | DPCI | OTHER | 302694 | 01 | UNSION | OTHER | 1417990185 | 05 | DE | MEDICAID |