Healthcare Provider Details

I. General information

NPI: 1346610094
Provider Name (Legal Business Name): USIMC OF WEST VIRGINIA MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 COLLINS FERRY RD
MORGANTOWN WV
26505-2356
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 304-554-5298
  • Fax: 304-598-5445
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN B LEIZMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 844-407-7557