Basic Information
| Provider Information | |||||||||
| NPI: | 1801866538 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION CHARLESTON DIVISION | ||||||||
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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: | 3110 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043471290 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 12/01/2017 | ||||||||
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| AuthorizedOfficialLastName: | HALEY | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | WEISE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3043471297 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4002106000 | 05 | WV | MEDICAID | 5305003000 | 05 | WV | MEDICAID | 51D0694530 | 01 | WV | CLIA | OTHER | 51D0694532 | 01 | WV | CLIA | OTHER | 5305001000 | 05 | WV | MEDICAID | 51D0694531 | 01 | WV | CLIA | OTHER | 51D0695014 | 01 | WV | CLIA | OTHER | 51D0694533 | 01 | WV | CLIA | OTHER | 51D0695013 | 01 | WV | CLIA | OTHER |