Basic Information
Provider Information | |||||||||
NPI: | 1568769354 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WVUPC-MEDICINE & SPECIALTY OFFICE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WVU PHYSICIANS OF CHARLESTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7000 | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265077000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042937401 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4522 MACCORKLE AVE SE | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253041840 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043471296 | ||||||||
FaxNumber: | 3043471394 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2011 | ||||||||
LastUpdateDate: | 02/15/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER | ||||||||
AuthorizedOfficialFirstName: | TERRY | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS ANALYST | ||||||||
AuthorizedOfficialTelephone: | 3042935033 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
ID | Type | State | Issuer | Description | 00 | 01 | WV | WC FACILITY SUFFIX | OTHER | 4002106000 | 05 | WV |   | MEDICAID | 51D0695014 | 01 | WV | CLIA FACILITY LAB NUMBER | OTHER | 121 | 01 | WV | WV BLUE SHIELD SUFFIX | OTHER |