Provider Demographics
NPI:1689735565
Name:MARTINSBURG INTERNAL MEDICINE ASSOC INC
Entity Type:Organization
Organization Name:MARTINSBURG INTERNAL MEDICINE ASSOC INC
Other - Org Name:MARTINSBURG INTERNAL MEDICINE LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:B
Authorized Official - Last Name:JALAZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-263-0913
Mailing Address - Street 1:1002 SUSHRUTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401
Mailing Address - Country:US
Mailing Address - Phone:304-263-0913
Mailing Address - Fax:304-267-2917
Practice Address - Street 1:1002 SUSHRUTA DRIVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-0913
Practice Address - Fax:304-267-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0008030001Medicaid