Basic Information
| Provider Information | |||||||||
| NPI: | 1477516722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1307 LAFAYETTE AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNDSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260412316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048452500 | ||||||||
| FaxNumber: | 3048452624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 LAFAYETTE AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNDSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260412316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048452500 | ||||||||
| FaxNumber: | 3048452624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 839 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0050728000 | 05 | WV | MEDICAID |