1992826176 NPI number — WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC

Table of content: (NPI 1992826176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992826176 NPI number — WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST VIRGINIA SCHOOL OF OSTEOPATHIC MEDICINE CLINIC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ROBERT C. BYRD CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992826176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 NORTH JEFFERSON STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-645-3220
Provider Business Mailing Address Fax Number:
304-645-4103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1464 JEFFERSON ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24901-1380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-645-3220
Provider Business Practice Location Address Fax Number:
304-793-2491
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLUNG
Authorized Official First Name:
JILL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR OF BUSINESS OPERATIONS
Authorized Official Telephone Number:
304-645-3220

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0006045004 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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