MEDICARE: BERKELEY FAMILY MEDICINA ASSOCIATES LAB

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	51D0234567	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	C10269	OTHER	WV	RAILROAD GROUP #
3	001709694	OTHER	WV	MTN STATE GROUP #

General Provider Information

NPI Number	:	1518028521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERKELEY FAMILY MEDICINA ASSOCIATES LAB

Provider Business Mailing Address
First Line	:	101 MARCLEY DR
Second Line	:
City	:	MARTINSBURG
State	:	WV
Zip	:	25401-2977
Country	:	US
Telephone Number	:	304-263-8911
Fax Number	:	304-263-9098

Provider Business Practice Location Address
First Line	:	101 MARCLEY DR
Second Line	:
City	:	MARTINSBURG
State	:	WV
Zip	:	25401-2977
Country	:	US
Telephone Number	:	304-263-8911
Fax Number	:	304-263-9098

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SUMMER D MOORE
Credential	:
Telephone Number	:	304-263-8911

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	05/15/2008

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