Healthcare Provider Details

I. General information

NPI: 1679321368
Provider Name (Legal Business Name): WEST VIRGINIA UNIVERSITY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 SUNCREST TOWN CENTRE DR
MORGANTOWN WV
26505-1875
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 45-984-8003
  • Fax: 45-997-3293
Mailing address:
  • Phone: 304-285-7101
  • Fax: 304-293-6963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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