Healthcare Provider Details

I. General information

NPI: 1912531724
Provider Name (Legal Business Name): JEFFREY GARAVAGLIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

379 JACOBS DR
MORGANTOWN WV
26505-7201
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4000
  • Fax:
Mailing address:
  • Phone: 314-640-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License NumberRP0007721
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: