Provider Demographics
NPI:1518028521
Name:BERKELEY FAMILY MEDICINA ASSOCIATES LAB
Entity Type:Organization
Organization Name:BERKELEY FAMILY MEDICINA ASSOCIATES LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-263-8911
Mailing Address - Street 1:101 MARCLEY DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2977
Mailing Address - Country:US
Mailing Address - Phone:304-263-8911
Mailing Address - Fax:304-263-9098
Practice Address - Street 1:101 MARCLEY DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2977
Practice Address - Country:US
Practice Address - Phone:304-263-8911
Practice Address - Fax:304-263-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51D0234567291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011451001Medicaid
WVC10269OtherRAILROAD GROUP #
WV001709694OtherMTN STATE GROUP #
WVC10269OtherRAILROAD GROUP #