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?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty