Healthcare Provider Details

I. General information

NPI: 1245625581
Provider Name (Legal Business Name): WVU MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 MEDICAL PARK DRIVE
BRIDGEPORT WV
26330-9010
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 681-342-3500
  • Fax: 681-342-1957
Mailing address:
  • Phone: 304-285-7100
  • Fax: 304-285-7126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREA M RUMBLE
Title or Position: PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 304-285-7101