1326044710 NPI number — MICHAEL M BOUSTANY MD INC

Table of content: (NPI 1326044710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326044710 NPI number — MICHAEL M BOUSTANY MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL M BOUSTANY MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326044710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3850
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25338-3850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-233-9314
Provider Business Mailing Address Fax Number:
304-233-0265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 MORRIS ST
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25301-1840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-343-7557
Provider Business Practice Location Address Fax Number:
304-343-3441
Provider Enumeration Date:
06/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BOUSTANY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-343-7557

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  10600 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2086S0129X , with the licence number: 10600 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2065901 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6953086900 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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