Provider Demographics
NPI:1639308471
Name:WVU SPORTS MEDICINE - UHA
Entity Type:Organization
Organization Name:WVU SPORTS MEDICINE - UHA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-293-5033
Mailing Address - Street 1:PO 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:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:943 MAPLE DR LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2812
Practice Address - Country:US
Practice Address - Phone:304-598-4830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011526000Medicaid
WV0011526000Medicaid