Individual
CHANCHAI TIVITMAHAISOON
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
20 HOSPITAL DR, LOGAN, WV 25601-3452
(304) 831-1254
(304) 831-1679
Mailing address
20 HOSPITAL DR, LOGAN, WV 25601-3452
(304) 831-1254
(304) 831-1679
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
11491
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0127820000
—
WV
Enumeration date
04/14/2006
Last updated
07/08/2007
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