Provider Demographics
NPI:1467560326
Name:SOULE, JEREMY B (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:B
Last Name:SOULE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 763
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0763
Mailing Address - Country:US
Mailing Address - Phone:800-541-4009
Mailing Address - Fax:
Practice Address - Street 1:16 STERLING DR
Practice Address - Street 2:SUITE 102
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9132
Practice Address - Country:US
Practice Address - Phone:304-326-2320
Practice Address - Fax:304-326-2323
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20980207RE0101X
WV19264207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC209802Medicaid
SC209802Medicaid
SCG83493Medicare ID - Type Unspecified