Provider Demographics
NPI:1467667030
Name:WVU MED CORP (MDGRP)
Entity Type:Organization
Organization Name:WVU MED CORP (MDGRP)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-293-5033
Mailing Address - Street 1:P O 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:304-293-5033
Mailing Address - Fax:309-293-6963
Practice Address - Street 1:255 SCOTT AVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-8803
Practice Address - Country:US
Practice Address - Phone:304-293-5033
Practice Address - Fax:304-293-6963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0011526000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9121131Medicare ID - Type Unspecified