Provider Demographics
NPI:1730151010
Name:ACKERMAN, ALICE JODY (DO)
Entity type:Individual
Prefix:DR
First Name:ALICE
Middle Name:JODY
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HEALTHCARE DR
Mailing Address - Street 2:MANSFIELD HILL
Mailing Address - City:PHILIPPI
Mailing Address - State:WV
Mailing Address - Zip Code:26416-9405
Mailing Address - Country:US
Mailing Address - Phone:304-457-1760
Mailing Address - Fax:304-457-3781
Practice Address - Street 1:1 HEALTHCARE DR
Practice Address - Street 2:MANSFIELD HILL
Practice Address - City:PHILIPPI
Practice Address - State:WV
Practice Address - Zip Code:26416
Practice Address - Country:US
Practice Address - Phone:304-457-1760
Practice Address - Fax:304-457-3781
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2159207Q00000X, 207P00000X
PA05-009868-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001817913OtherMOUNTAIN STATE BCS
P00375987OtherRAILROAD MEDICARE
PA001782911 (00008)Medicaid
WV3810004790Medicaid
WV02159AOtherTHE HEALTH PLAN
WV001817913OtherMOUNTAIN STATE BCS
P00375987OtherRAILROAD MEDICARE
PA035755 RQUMedicare ID - Type Unspecified