Provider Demographics
NPI:1831379338
Name:COAL COUNTRY CLINIC INC
Entity type:Organization
Organization Name:COAL COUNTRY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:MERRITT
Authorized Official - Last Name:KOSTENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-763-0199
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-0088
Mailing Address - Country:US
Mailing Address - Phone:304-763-0199
Mailing Address - Fax:304-763-2137
Practice Address - Street 1:3050 C AND O DAM RD
Practice Address - Street 2:
Practice Address - City:DANIELS
Practice Address - State:WV
Practice Address - Zip Code:25832-9718
Practice Address - Country:US
Practice Address - Phone:304-763-0199
Practice Address - Fax:304-763-2137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1078208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9243402Medicare PIN