Provider Demographics
NPI:1295943777
Name:WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION CHARLESTON DIVISION
Entity type:Organization
Organization Name:WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION CHARLESTON DIVISION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-293-5033
Mailing Address - Street 1:P O 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:304-293-5033
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:3110 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:26507-7000
Practice Address - Country:US
Practice Address - Phone:304-293-5033
Practice Address - Fax:304-293-6963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4002106000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9316862Medicare ID - Type Unspecified