Provider Demographics
NPI:1548454986
Name:MEDICAL ASSOCIATES OF GLEN DANIEL
Entity type:Organization
Organization Name:MEDICAL ASSOCIATES OF GLEN DANIEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:JORGE
Authorized Official - Last Name:GORDINHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-934-5125
Mailing Address - Street 1:PO BOX 216
Mailing Address - Street 2:
Mailing Address - City:GLEN DANIEL
Mailing Address - State:WV
Mailing Address - Zip Code:25844-0216
Mailing Address - Country:US
Mailing Address - Phone:304-934-5125
Mailing Address - Fax:304-934-6967
Practice Address - Street 1:109 BOLT RD
Practice Address - Street 2:
Practice Address - City:GLEN DANIEL
Practice Address - State:WV
Practice Address - Zip Code:25844-0216
Practice Address - Country:US
Practice Address - Phone:304-934-5125
Practice Address - Fax:304-934-6967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV026920251J00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251J00000XAgenciesNursing Care