Provider Demographics
NPI:1346610094
Name:USIMC OF WEST VIRGINIA MEDICAL CORPORATION
Entity Type:Organization
Organization Name:USIMC OF WEST VIRGINIA MEDICAL CORPORATION
Other - Org Name:MYLAN HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:844-407-7557
Mailing Address - Street 1:5500 MARYLAND WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4993
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3711 COLLINS FERRY RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2356
Practice Address - Country:US
Practice Address - Phone:304-554-5298
Practice Address - Fax:304-598-5445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty