Provider Demographics
NPI:1033128970
Name:MORGANTOWN UROLOGIC ASSOCIATES, INC
Entity Type:Organization
Organization Name:MORGANTOWN UROLOGIC ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:WILDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MARSTILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-598-2906
Mailing Address - Street 1:1000 J D ANDERSON DR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1238
Mailing Address - Country:US
Mailing Address - Phone:304-598-2906
Mailing Address - Fax:304-599-1802
Practice Address - Street 1:1000 J D ANDERSON DR
Practice Address - Street 2:SUITE 401
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1238
Practice Address - Country:US
Practice Address - Phone:304-598-2906
Practice Address - Fax:304-599-1802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001709698OtherBLUE CROSS BLUE SHIELD
WV0851442OtherUMWA
WV0007813000Medicaid
WV0007813000Medicaid