NPIMap

Organization Active NPI

West Virginia Dermatology and Skin Surgery Center

  • Medical Specialty Clinic/Center
  • South Charleston, WV
National Provider Identifier
1174881916
Registry record updated Jan 6, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Specialty Clinic/CenterTaxonomy code 261QM2500X
License
2596 Issued in WV
Legal business name
WEST VIRGINIA DERMATOLOGY AND SKIN SURGERY CENTER
Practice address
4202 Maccorkle Ave SW Ste 200
South Charleston, WV 25309-1513
Phone
(304) 925-7546
Fax
(681) 205-8369
NPI assigned
Apr 30, 2012
Last updated
Jan 6, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 6, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. David W Judy, D.O.NPI 1619144433
Title
Owner
Phone
(304) 925-7546

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Specialty Clinic/Center 261QM2500X 2596 WV Primary

Addresses

Primary practice location

4202 Maccorkle Ave SW Ste 200
South Charleston, WV 25309-1513

Mailing address

4202 Maccorkle Ave SW Ste 200
South Charleston, WV 25309-1513
Phone (304) 925-7546

Other names 1

  • West Virginia Dermatology Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120809000007 WV Part B Supplier - Clinic/Group Practice 7214183136 Receives reassigned benefits from 6 practitioners
Practice locations: Barboursville, WV; S Charleston, WV

National Provider Directory

National Provider Directory

Locations

4202 Maccorkle Ave SW
South Charleston, WV 25309
Phone (304) 925-4761

4202 Maccorkle Ave SW
#200
South Charleston, WV 25309
Phone (304) 925-7546

4610 Kanawha Ave SW
Ste 302
South Charleston, WV 25309
Phone (304) 766-0009

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1335744000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1578268800000",
    "number": "1174881916",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4202 MACCORKLE AVE SW STE 200",
            "city": "SOUTH CHARLESTON",
            "state": "WV",
            "postal_code": "253091513",
            "telephone_number": "304-925-7546",
            "fax_number": "681-205-8369"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4202 MACCORKLE AVE SW STE 200",
            "city": "SOUTH CHARLESTON",
            "state": "WV",
            "postal_code": "253091513",
            "telephone_number": "304-925-7546",
            "fax_number": "681-205-8369"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WEST VIRGINIA DERMATOLOGY AND SKIN SURGERY CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-04-30",
        "last_updated": "2020-01-06",
        "certification_date": "2020-01-06",
        "status": "A",
        "authorized_official_last_name": "JUDY",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "304-925-7546",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": "WV",
            "license": "2596",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "West Virginia Dermatology",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "West Virginia Dermatology",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in South Charleston, WV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.