Basic Information
| Provider Information | |||||||||
| NPI: | 1831496629 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WVUPC-CAMC MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WVU PHYSICIANS OF CHARLESTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7000 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265077000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3200 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043471296 | ||||||||
| FaxNumber: | 3043471394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2011 | ||||||||
| LastUpdateDate: | 02/15/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 3042935033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 001703805 | 01 | WV | WV BLUE SHIELD FACILITY ID | OTHER | 51D0695014 | 01 | WV | CLIA FACILITY LAB NUMBER | OTHER | 400216000 | 05 | WV | MEDICAID |