Provider Demographics
NPI:1730216557
Name:MEDICAL ASSOCIATES OF GLEN DANIELS, PLLC
Entity type:Organization
Organization Name:MEDICAL ASSOCIATES OF GLEN DANIELS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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
Mailing Address - Country:US
Mailing Address - Phone:304-934-5125
Mailing Address - Fax:304-934-6967
Practice Address - Street 1:264 COAL RIVER RD
Practice Address - Street 2:
Practice Address - City:GLEN DANIEL
Practice Address - State:WV
Practice Address - Zip Code:25844-9402
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:2007-02-28
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003365Medicaid
WV3810003365Medicaid