=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750786844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEDGEWOOD FAMILY PRACTICE & PSYCHIATRY ASSOCIATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2014
-----------------------------------------------------
Last Update Date | 10/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1197 VAN VOORHIS RD
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26505-3478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-598-2233
-----------------------------------------------------
Fax | 304-296-1792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 FAIRMONT RD
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-3847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-598-2233
-----------------------------------------------------
Fax | 304-296-1792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | FRANK ORTIZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-598-2233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------