Basic Information
| Provider Information | |||||||||
| NPI: | 1649559972 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WVU MEDICAL OFFICE BUILDING | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 780 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
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| Practice Location | |||||||||
| Address1: | 203 E 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | RANSON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254381617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2011 | ||||||||
| LastUpdateDate: | 08/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | RUMBLE | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3042935033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 51D1063492 | WV | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0011526000 | 05 | WV | MEDICAID |