Basic Information
| Provider Information | |||||||||
| NPI: | 1780973792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | MA THERESA | ||||||||
| MiddleName: | CONCEPCION | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MORRIS ST | ||||||||
| Address2: | STE 357 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043883574 | ||||||||
| FaxNumber: | 3043886481 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MORRIS ST | ||||||||
| Address2: | 3 WEST ADMINISTRATION | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043883574 | ||||||||
| FaxNumber: | 3043886481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2011 | ||||||||
| LastUpdateDate: | 11/24/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 25853 | WV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.