Healthcare Provider Details

I. General information

NPI: 1003205402
Provider Name (Legal Business Name): MORGANTOWN OBSTETRIC AND GYNECOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1191 PINEVIEW DR STE H
MORGANTOWN WV
26505-2778
US

IV. Provider business mailing address

1191 PINEVIEW DR STE H
MORGANTOWN WV
26505-2778
US

V. Phone/Fax

Practice location:
  • Phone: 304-212-5620
  • Fax: 304-241-4645
Mailing address:
  • Phone: 304-212-5620
  • Fax: 304-241-4645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number50130
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number17237
License Number StateWV

VIII. Authorized Official

Name: MURSHID K ABDEL-LATIF
Title or Position: OWNER
Credential: M.D.
Phone: 304-212-5620