Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 13066 | WV |
NPI | 1235257973 |
---|---|
Provider Name | Dr. David Montgomery Mclellan |
First Address | Fairmont, WV 26554-1332 |
Second Address | Fairmont, WV 26554-1332 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0128367000 | (05) | WV |
E84763 | (02) | WV |