Provider Demographics
NPI:1588916399
Name:WV ASTHMA AND ALLERGY CENTERS, INC.
Entity type:Organization
Organization Name:WV ASTHMA AND ALLERGY CENTERS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATHENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-343-4300
Mailing Address - Street 1:208 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1160
Mailing Address - Country:US
Mailing Address - Phone:304-343-4300
Mailing Address - Fax:304-343-5473
Practice Address - Street 1:401 6TH AVE
Practice Address - Street 2:SUITE 303D
Practice Address - City:MONTGOMERY
Practice Address - State:WV
Practice Address - Zip Code:25136-2116
Practice Address - Country:US
Practice Address - Phone:304-343-4300
Practice Address - Fax:304-343-5473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV78687207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0006123000Medicaid