Provider Demographics
NPI:1215916614
Name:EGGLESTON, ROBERT MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:EGGLESTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 6TH AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MONTGOMERY
Mailing Address - State:WV
Mailing Address - Zip Code:25136-2116
Mailing Address - Country:US
Mailing Address - Phone:304-442-2521
Mailing Address - Fax:304-442-7463
Practice Address - Street 1:401 6TH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:MONTGOMERY
Practice Address - State:WV
Practice Address - Zip Code:25136-2116
Practice Address - Country:US
Practice Address - Phone:304-442-2521
Practice Address - Fax:304-442-7463
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19618207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5600480000Medicaid
WV0883036Medicare PIN
WV5600480000Medicaid
WVEG0883035Medicare PIN
WVP00212077Medicare PIN
WVEG0883034Medicare PIN