Provider Demographics
NPI:1316350556
Name:MED EX PLLC
Entity type:Organization
Organization Name:MED EX PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-868-6000
Mailing Address - Street 1:705 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-1729
Mailing Address - Country:US
Mailing Address - Phone:800-824-2543
Mailing Address - Fax:304-485-4466
Practice Address - Street 1:705 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1729
Practice Address - Country:US
Practice Address - Phone:304-868-6000
Practice Address - Fax:304-868-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1455291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009472Medicaid