Provider Demographics
NPI:1831378504
Name:ST. MARY'S MEDICAL MANAGEMENT HIGHLAWN LAB
Entity type:Organization
Organization Name:ST. MARY'S MEDICAL MANAGEMENT HIGHLAWN LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-399-7565
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-0088
Mailing Address - Country:US
Mailing Address - Phone:304-536-5030
Mailing Address - Fax:304-536-5031
Practice Address - Street 1:2828 1ST AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1236
Practice Address - Country:US
Practice Address - Phone:304-399-7565
Practice Address - Fax:304-399-7568
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S MEDICAL MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-30
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009673Medicaid