Provider Demographics
NPI:1548285117
Name:PARKERSBURG SURGICAL ASSOCIATES, PLLC
Entity type:Organization
Organization Name:PARKERSBURG SURGICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-865-4345
Mailing Address - Street 1:800 GRAND CENTRAL MALL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4131
Mailing Address - Country:US
Mailing Address - Phone:304-865-4345
Mailing Address - Fax:304-420-5995
Practice Address - Street 1:800 GRAND CENTRAL MALL
Practice Address - Street 2:SUITE 2
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-4131
Practice Address - Country:US
Practice Address - Phone:304-865-4345
Practice Address - Fax:304-420-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011154000Medicaid
WV1043080OtherWV COMP
WV0005186653OtherAETNA
WV9298571OtherMEDICARE PTAN
OH2197448Medicaid
WV001707362OtherMOUNTAIN STATE BCBS
WV0005186653OtherAETNA
WV========= 0010OtherCIGNA