Provider Demographics
NPI:1124202312
Name:MATULAVICH, RITA L (CRNA)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:L
Last Name:MATULAVICH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 897
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0897
Mailing Address - Country:US
Mailing Address - Phone:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:101 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-598-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV60036367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVCA7030OtherRAILROAD MEDICARE GROUP
WVP00610982OtherRAILROAD MEDICARE
WV9121131OtherMEDICARE GROUP
WV3810011542Medicaid
WV9121131OtherMEDICARE GROUP