Basic Information
| Provider Information | |||||||||
| NPI: | 1811196314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAYRE | ||||||||
| OtherFirstName: | ANITA | ||||||||
| OtherMiddleName: | R. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 337 | ||||||||
| Address2: | 908 SCARBRO ROAD | ||||||||
| City: | SCARBRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259170337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045743960 | ||||||||
| FaxNumber: | 3045742179 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 W MAPLE AVENUE | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258401413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045743960 | ||||||||
| FaxNumber: | 3045743960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 09/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2362 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810016406 | 05 | WV | MEDICAID |