Healthcare Provider Details

I. General information

NPI: 1649559972
Provider Name (Legal Business Name): WVU MEDICAL OFFICE BUILDING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E 4TH AVE
RANSON WV
25438-1617
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number51D1063492
License Number StateWV

VIII. Authorized Official

Name: ANDREA RUMBLE
Title or Position: PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 304-293-5033