Provider Demographics
NPI:1417393570
Name:MORGANTOWN ENT AND NEUROLOGY-SUNCREST
Entity Type:Organization
Organization Name:MORGANTOWN ENT AND NEUROLOGY-SUNCREST
Other - Org Name:UNIVERSITY HEALTH ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROBVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-285-7101
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0780
Mailing Address - Country:US
Mailing Address - Phone:304-285-7100
Mailing Address - Fax:304-285-7126
Practice Address - Street 1:1065 SUNCREST TOWNE CENTRE DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:PA
Practice Address - Zip Code:26505-2712
Practice Address - Country:US
Practice Address - Phone:304-599-3959
Practice Address - Fax:304-599-7329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011526000Medicaid
WV0011526000Medicaid