Healthcare Provider Details

I. General information

NPI: 1639308471
Provider Name (Legal Business Name): WVU SPORTS MEDICINE - UHA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 MAPLE DR LOWR LEVEL
MORGANTOWN WV
26505-2812
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4830
  • Fax:
Mailing address:
  • Phone: 304-293-7401
  • Fax: 304-293-6963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBYN MCDANIEL
Title or Position: PROVIDER RELATIONS SUPERVISOR
Credential:
Phone: 304-293-5033