Provider Demographics
NPI:1407072408
Name:MONROE HEALTH CENTER-PETERSTOWN LAB
Entity Type:Organization
Organization Name:MONROE HEALTH CENTER-PETERSTOWN LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-772-3064
Mailing Address - Street 1:200 HEALTH CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:WV
Mailing Address - Zip Code:24983
Mailing Address - Country:US
Mailing Address - Phone:304-772-3064
Mailing Address - Fax:304-772-3296
Practice Address - Street 1:591 US HIGHWAY 219
Practice Address - Street 2:
Practice Address - City:PETERSTOWN
Practice Address - State:WV
Practice Address - Zip Code:24963
Practice Address - Country:US
Practice Address - Phone:304-753-4336
Practice Address - Fax:304-753-4097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001366Medicaid