Basic Information
| Provider Information | |||||||||
| NPI: | 1467667030 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WVU MED CORP (MDGRP) | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 780 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042935033 | ||||||||
| FaxNumber: | 3092936963 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 SCOTT AVE | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265088803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042935033 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 3042935033 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0011526000 | WV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.