MEDICARE: CLARKSBURG ENT - UHA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326277187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKSBURG ENT - UHA

Provider Business Mailing Address
First Line	:	PO BOX 780
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26507-0780
Country	:	US
Telephone Number	:	304-293-7401
Fax Number	:	304-293-6963

Provider Business Practice Location Address
First Line	:	700 GENESIS BLVD
Second Line	:
City	:	BRIDGEPORT
State	:	WV
Zip	:	26330-9668
Country	:	US
Telephone Number	:	304-598-4825
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER RELATIONS SUPERVISOR
Name	:	ROBYN M MCDANIEL
Credential	:
Telephone Number	:	304-293-5033

Provider Enumeration Date	:	07/14/2009
Last Update Date	:	07/14/2009

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