Provider Demographics
NPI:1104081686
Name:WESTON PRIMARY CARE, PLLC
Entity type:Organization
Organization Name:WESTON PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-517-1301
Mailing Address - Street 1:1 GARTON PLZ
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-2128
Mailing Address - Country:US
Mailing Address - Phone:304-517-1301
Mailing Address - Fax:304-517-1304
Practice Address - Street 1:1 GARTON PLZ
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-2128
Practice Address - Country:US
Practice Address - Phone:304-517-1301
Practice Address - Fax:304-517-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV2054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006556Medicaid
WVI53823Medicare UPIN
WV3810006556Medicaid