Provider Demographics
NPI:1518040633
Name:MORGANTOWN SURGICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:MORGANTOWN SURGICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-599-1448
Mailing Address - Street 1:200 WEDGEWOOD DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2442
Mailing Address - Country:US
Mailing Address - Phone:304-599-1448
Mailing Address - Fax:304-599-5335
Practice Address - Street 1:200 WEDGEWOOD DR
Practice Address - Street 2:SUITE 202
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2442
Practice Address - Country:US
Practice Address - Phone:304-599-1448
Practice Address - Fax:304-599-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2630675OtherMEDICAID OF OHIO
WV0011401000Medicaid
610308000OtherOWPC
001709635OtherBLUE CROSS BLUE SHIELD
64239OtherUNISON
001709635OtherBLUE CROSS BLUE SHIELD