Healthcare Provider Details

I. General information

NPI: 1134331812
Provider Name (Legal Business Name): WEST VIRGINIA UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR WVU HEALTH SCIENCES CENTER
MORGANTOWN WV
26506-9247
US

IV. Provider business mailing address

1 MEDICAL CENTER DR WVU HEALTH SCIENCES CENTER
MORGANTOWN WV
26506-9247
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-1369
  • Fax: 304-293-2713
Mailing address:
  • Phone: 304-293-1369
  • Fax: 304-293-2713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number13865
License Number StateWV

VIII. Authorized Official

Name: DR. ROY GREGORY JUCKETT
Title or Position: ASSOC. PROFESSOR OF FAMILY MEDICINE
Credential: MD
Phone: 304-293-1369