Provider Demographics
NPI:1164670873
Name:PATHOLOGY LABORATORY FOR TRANSLATIONAL-UHA
Entity Type:Organization
Organization Name:PATHOLOGY LABORATORY FOR TRANSLATIONAL-UHA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-293-5033
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0897
Mailing Address - Country:US
Mailing Address - Phone:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:2189 HEALTH SCIENCE CENTER NORTH RM 2124
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-598-4800
Practice Address - Fax:304-293-6963
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-05
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51D1013450291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011526000Medicaid
51D1013450OtherCLIA
WV9121131Medicare PIN