Basic Information
| Provider Information | |||||||||
| NPI: | 1164670873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PATHOLOGY LABORATORY FOR TRANSLATIONAL-UHA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 897 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Practice Location | |||||||||
| Address1: | 2189 HEALTH SCIENCE CENTER NORTH RM 2124 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045984800 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2008 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 3042935033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 51D1013450 | WV | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0011526000 | 05 | WV | MEDICAID | 51D1013450 | 01 | CLIA | OTHER |