Basic Information
| Provider Information | |||||||||
| NPI: | 1700166659 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARRUTH CENTER-SSC | ||||||||
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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: | 700 COLLEGE AVENUE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265066422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042934431 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | RUMBLE | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALISTQ | ||||||||
| 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 | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.