Provider Demographics
NPI:1134331812
Name:WEST VIRGINIA UNIVERSITY
Entity Type:Organization
Organization Name:WEST VIRGINIA UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOC. PROFESSOR OF FAMILY MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:JUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-293-1369
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:WVU HEALTH SCIENCES CENTER
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-9247
Mailing Address - Country:US
Mailing Address - Phone:304-293-1369
Mailing Address - Fax:304-293-2713
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:WVU HEALTH SCIENCES CENTER
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-9247
Practice Address - Country:US
Practice Address - Phone:304-293-1369
Practice Address - Fax:304-293-2713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13865261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health