Basic Information
| Provider Information | |||||||||
| NPI: | 1578771523 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UHA JEFFERSON MAT CTR LAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 897 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042935033 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 S PRESTON ST | ||||||||
| Address2: | |||||||||
| City: | RANSON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254381628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042935033 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| 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 | 291U00000X | 6705075000 | WV | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.