Provider Demographics
NPI:1457499519
Name:MILEGROUND PHYSICIANS, PLLC
Entity Type:Organization
Organization Name:MILEGROUND PHYSICIANS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NORVAL
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-292-4996
Mailing Address - Street 1:1526 MILEGROUND RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3745
Mailing Address - Country:US
Mailing Address - Phone:304-292-4996
Mailing Address - Fax:304-292-9578
Practice Address - Street 1:1526 MILEGROUND RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3745
Practice Address - Country:US
Practice Address - Phone:304-292-4996
Practice Address - Fax:304-292-9578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11609208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVMI9312691Medicare ID - Type UnspecifiedGROUP #