Provider Demographics
NPI:1144340787
Name:APPLACHAIN PAIN THERAPY INSTITUTE
Entity type:Organization
Organization Name:APPLACHAIN PAIN THERAPY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSIAH
Authorized Official - Middle Name:KELLEY
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-925-2922
Mailing Address - Street 1:4407 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2505
Mailing Address - Country:US
Mailing Address - Phone:304-925-2922
Mailing Address - Fax:304-926-8009
Practice Address - Street 1:4407 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2505
Practice Address - Country:US
Practice Address - Phone:304-925-2922
Practice Address - Fax:304-926-8009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11322208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0201994000Medicaid
WV9339481Medicare ID - Type Unspecified
WV0201994000Medicaid