Healthcare Provider Details

I. General information

NPI: 1902014038
Provider Name (Legal Business Name): WVUPC KANAWHA VALLEY FP (PAASGRP)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 DIVISION STREET SUITE 205
SOUTH CHARLESTON WV
25309-0000
US

IV. Provider business mailing address

PO BOX 7000
MORGANTOWN WV
26507-7000
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-5033
  • Fax: 304-293-6963
Mailing address:
  • Phone: 304-293-5033
  • Fax: 304-293-6963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number67050360001
License Number StateWV

VIII. Authorized Official

Name: TERRY MILLER
Title or Position: PROVIDER RELATIONS ANALYST
Credential:
Phone: 304-293-5033