Provider Demographics
NPI:1386899664
Name:MICUCCI, CHAD JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:JOSEPH
Last Name:MICUCCI
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 1:200 ORTHOPEDIC WAY
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1240
Mailing Address - Country:US
Mailing Address - Phone:304-599-0720
Mailing Address - Fax:304-599-3962
Practice Address - Street 1:200 ORTHOPEDIC WAY
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1240
Practice Address - Country:US
Practice Address - Phone:304-599-0720
Practice Address - Fax:304-599-3962
Is Sole Proprietor?:No
Enumeration Date:2008-11-30
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24024207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018320Medicaid
WV3810018320Medicaid