Basic Information
| Provider Information | |||||||||
| NPI: | 1659713584 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INDRAMOHAN | ||||||||
| FirstName: | PAVITHRA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1249 15TH ST STE 4093 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013662 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1249 15TH ST STE 2000 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911000 | ||||||||
| FaxNumber: | 3046911693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT205046 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 27577 | WV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.