Provider Demographics
NPI:1386728202
Name:GREAT TEAYS MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:GREAT TEAYS MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-760-9250
Mailing Address - Street 1:3703 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9645
Mailing Address - Country:US
Mailing Address - Phone:304-760-9250
Mailing Address - Fax:304-760-9290
Practice Address - Street 1:3703 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9645
Practice Address - Country:US
Practice Address - Phone:304-760-9250
Practice Address - Fax:304-760-9290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVDB5783OtherRAILROAD MEDICARE
WV0007342019OtherAETNA/US HEALTHCARE
WV5425070001OtherMEDICARE DMERC
WV3810001783Medicaid
WVGR9341881Medicare ID - Type UnspecifiedGROUP NUMBER