Healthcare Provider Details

I. General information

NPI: 1649504283
Provider Name (Legal Business Name): BONNIE BUS - WVU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 STADIUM DR
MORGANTOWN WV
26506-7911
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4000
  • Fax:
Mailing address:
  • Phone: 304-285-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREA M RUMBLE
Title or Position: PROVIDER RELATIONS SUPERVISOR
Credential:
Phone: 304-285-7101