Basic Information
| Provider Information | |||||||||
| NPI: | 1790924454 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST VIRGINIA UNIVERSITY PHYSICIAN OF CHARLESTON-VALLEY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7000 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265077000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 LINCOLN DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253092304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047684410 | ||||||||
| FaxNumber: | 3047684416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2009 | ||||||||
| LastUpdateDate: | 02/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCDANIEL | ||||||||
| AuthorizedOfficialFirstName: | ROBYN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3042935033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST VIRGINIA UNIVERSITY PHYSICIANS OF CHARLESTON | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4002106000 | 05 | WV | MEDICAID |