Basic Information
| Provider Information | |||||||||
| NPI: | 1972582542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARMON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 MACCORKLE AVE SE | ||||||||
| Address2: | SUITE B1 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043450667 | ||||||||
| FaxNumber: | 3043450418 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 MACCORKLE AVE SE | ||||||||
| Address2: | SUITE B1 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043450667 | ||||||||
| FaxNumber: | 3043450418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 04/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 14790 | WV | Y | Other Service Providers | Specialist |
No ID Information.