Basic Information
Provider Information | |||||||||
NPI: | 1306125612 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY HEMATOLOGY AND ONCOLOGY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 780 | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265070780 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042937401 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2008 PROFESSIONAL CT | ||||||||
Address2: |   | ||||||||
City: | MARTINSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 254018808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042937401 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2011 | ||||||||
LastUpdateDate: | 08/04/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUMBLE | ||||||||
AuthorizedOfficialFirstName: | ANDREA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3042935033 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WEST VIRGINIA UNIVERSITY MEDICAL CORP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 51D2024487 | WV | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 0011526000 | 05 | WV |   | MEDICAID |