Provider Demographics
NPI:1992826176
Name:WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC
Entity Type:Organization
Organization Name:WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC
Other - Org Name:ROBERT C. BYRD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-645-3220
Mailing Address - Street 1:400 NORTH JEFFERSON STREET
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901
Mailing Address - Country:US
Mailing Address - Phone:304-645-3220
Mailing Address - Fax:304-645-4103
Practice Address - Street 1:1464 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1380
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:304-793-2491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0006045004Medicaid