Provider Demographics
NPI: | 1700166659 |
---|---|
Name: | CARRUTH CENTER-SSC |
Entity Type: | Organization |
Organization Name: | CARRUTH CENTER-SSC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PROVIDER ENROLLMENT SPECIALISTQ |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ANDREA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | RUMBLE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 304-293-5033 |
Mailing Address - Street 1: | PO 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: | 304-293-7401 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 700 COLLEGE AVENUE |
Practice Address - Street 2: | 3RD FLOOR |
Practice Address - City: | MORGANTOWN |
Practice Address - State: | WV |
Practice Address - Zip Code: | 26506-6422 |
Practice Address - Country: | US |
Practice Address - Phone: | 304-293-4431 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2011-08-24 |
Last Update Date: | 2011-08-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |