MEDICARE: PATHOLOGY LABORATORY FOR TRANSLATIONAL-UHA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	51D1013450	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	51D1013450	OTHER		CLIA

General Provider Information

NPI Number	:	1164670873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHOLOGY LABORATORY FOR TRANSLATIONAL-UHA

Provider Business Mailing Address
First Line	:	PO BOX 897
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26507-0897
Country	:	US
Telephone Number	:	304-293-7401
Fax Number	:	304-293-6963

Provider Business Practice Location Address
First Line	:	2189 HEALTH SCIENCE CENTER NORTH RM 2124
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26506
Country	:	US
Telephone Number	:	304-598-4800
Fax Number	:	304-293-6963

Authorized Official
Title or Position	:	PROVIDER RELATIONS ANALYST
Name	:	TERRY D MILLER
Credential	:
Telephone Number	:	304-293-5033

Provider Enumeration Date	:	09/05/2008
Last Update Date	:	06/25/2009

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