Healthcare Provider Details

I. General information

NPI: 1114170693
Provider Name (Legal Business Name): WVUPC-KANAWHA VALLEY FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 DIVISION ST SUITE 205
S CHARLESTON WV
25309-1455
US

IV. Provider business mailing address

PO BOX 7000
MORGANTOWN WV
26507-7000
US

V. Phone/Fax

Practice location:
  • Phone: 304-768-3941
  • Fax:
Mailing address:
  • Phone: 304-293-7401
  • Fax: 304-293-6963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBYN M MCDANIEL
Title or Position: PROVIDER RELATIONS SUPERVISOR
Credential:
Phone: 304-293-5033