Basic Information
| Provider Information | |||||||||
| NPI: | 1275727547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UHA-UNIVERSITY MEDICAL & SURGICAL LAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 897 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 E 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | RANSON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254381613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047256343 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | HENSON | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3042935033 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | WV | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0011526000 | 05 | WV | MEDICAID | 3810009071 | 05 | WV | MEDICAID |