Provider Demographics
NPI:1942507595
Name:WVUPC QUARRY MANOR
Entity Type:Organization
Organization Name:WVUPC QUARRY MANOR
Other - Org Name:WVU PHYSICIANS OF CHARLESTON
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:304-293-7401
Mailing Address - Fax:
Practice Address - Street 1:699 S PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2627
Practice Address - Country:US
Practice Address - Phone:304-347-1296
Practice Address - Fax:304-347-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4002106000Medicaid
WVWV9316862Medicare PIN