Healthcare Provider Details

I. General information

NPI: 1568769354
Provider Name (Legal Business Name): WVUPC-MEDICINE & SPECIALTY OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4522 MACCORKLE AVE SE
CHARLESTON WV
25304-1840
US

IV. Provider business mailing address

PO BOX 7000
MORGANTOWN WV
26507-7000
US

V. Phone/Fax

Practice location:
  • Phone: 304-347-1296
  • Fax: 304-347-1394
Mailing address:
  • Phone: 304-293-7401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERRY D MILLER
Title or Position: PROVIDER RELATIONS ANALYST
Credential:
Phone: 304-293-5033