Basic Information
| Provider Information | |||||||||
| NPI: | 1922423292 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GYNECOLOGIC ASSOCIATES OF PARKERSBURG, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 GARFIELD AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261015444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044854700 | ||||||||
| FaxNumber: | 3044854466 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 GARFIELD AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261015444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044242035 | ||||||||
| FaxNumber: | 3044242024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2014 | ||||||||
| LastUpdateDate: | 02/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHOCKLEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3044242035 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 3810007580 | 05 | WV | MEDICAID |