Provider Demographics
NPI:1568671980
Name:WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION CHARLESTON DIVISION
Entity Type:Organization
Organization Name:WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION CHARLESTON DIVISION
Other - Org Name:WVUPC FAMILY MED CTR CHAS (PAASGRP)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-293-5033
Mailing Address - Street 1:PO BOX 7000
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-7000
Mailing Address - Country:US
Mailing Address - Phone:304-293-5033
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:1201 WASHINGTON ST E
Practice Address - Street 2:SUITE 108
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1834
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:2007-05-22
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV6705038001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9316862Medicare ID - Type Unspecified