Provider Demographics
NPI:1457605404
Name:WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION
Other - Org Name:WVU OBSTETRICS & GYNECOLOGY-BRIDGEPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
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:304-285-7101
Mailing Address - Street 1:P O BOX 780
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0780
Mailing Address - Country:US
Mailing Address - Phone:304-285-7101
Mailing Address - Fax:
Practice Address - Street 1:527 MEDICAL PARK DR
Practice Address - Street 2:SUITE 108
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9008
Practice Address - Country:US
Practice Address - Phone:304-848-2152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51D2012387291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011526000Medicaid
9121131Medicare PIN