Provider Demographics
NPI:1295743839
Name:MIMNAGH, KATHLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:MIMNAGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2484
Mailing Address - Country:US
Mailing Address - Phone:304-744-4496
Mailing Address - Fax:304-388-9633
Practice Address - Street 1:3200 MACCORKLE AVE
Practice Address - Street 2:CAMC -MEMORIAL HOSPITAL, ADMINISTRATION
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-4377
Practice Address - Fax:304-388-9633
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16906207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0078598000Medicaid
MAMSIOther292056
4263984OtherAETNA
F35234Medicare UPIN