Basic Information
Provider Information | |||||||||
NPI: | 1609975333 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PLEASANT VALLEY EMERGENCY PHYSICIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2520 VALLEY DR | ||||||||
Address2: |   | ||||||||
City: | PT PLEASANT | ||||||||
State: | WV | ||||||||
PostalCode: | 255502031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046754340 | ||||||||
FaxNumber: | 3046751328 | ||||||||
Practice Location | |||||||||
Address1: | 2520 VALLEY DR | ||||||||
Address2: |   | ||||||||
City: | PT PLEASANT | ||||||||
State: | WV | ||||||||
PostalCode: | 25550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046754340 | ||||||||
FaxNumber: | 3046751328 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2006 | ||||||||
LastUpdateDate: | 05/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAYNE | ||||||||
AuthorizedOfficialFirstName: | ROBIN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALLING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3046754340 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 945 | WV | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 1441 | WV | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 905 | WV | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 18261 | WV | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 1102 | WV | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0164227 | 05 | OH |   | MEDICAID | 0009656000 | 05 | WV |   | MEDICAID | 001710511 | 01 | WV | BCBS | OTHER |