Healthcare Provider Details

I. General information

NPI: 1942058466
Provider Name (Legal Business Name): WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 DOCTOR OATES DR STE 105
MARTINSBURG WV
25401-8896
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 304-596-5780
  • Fax: 304-596-5781
Mailing address:
  • Phone: 304-285-7101
  • Fax: 304-293-6963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN GIBSON
Title or Position: VP, FINANCE
Credential:
Phone: 304-598-4256