Provider Demographics
NPI:1841528577
Name:STEPHAN J SERFONTEIN MD PLLC
Entity type:Organization
Organization Name:STEPHAN J SERFONTEIN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANUS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SERFONTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-675-6835
Mailing Address - Street 1:PO BOX 534
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-0534
Mailing Address - Country:US
Mailing Address - Phone:304-675-6835
Mailing Address - Fax:304-675-6849
Practice Address - Street 1:2418 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-1528
Practice Address - Country:US
Practice Address - Phone:304-675-6835
Practice Address - Fax:304-675-6849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21778207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVI27081Medicare UPIN