1245329705 NPI number — GARRISON V. MORIN DBA MOUNTAIN STATE ENT CENTER

Table of content: (NPI 1245329705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245329705 NPI number — GARRISON V. MORIN DBA MOUNTAIN STATE ENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARRISON V. MORIN DBA MOUNTAIN STATE ENT CENTER
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:
Provider Other Organization Name Type Code:
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:
1245329705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
321 LUTZ AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MARTINSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25404-6362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-267-0235
Provider Business Mailing Address Fax Number:
304-267-0237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 LUTZ AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MARTINSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25404-6362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-267-0235
Provider Business Practice Location Address Fax Number:
304-267-0237
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORIN
Authorized Official First Name:
GARRISON
Authorized Official Middle Name:
VASILE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-267-0235

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  21819 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3810001886 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00212257 . This is a "MORIN MCARE RAILROAD INDI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2132881 . This is a "MORIN MAMSI INDIVIDUAL" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1003874934 . This is a "MORIN NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: DD1745 . This is a "MEDICARE RAILROAD: GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7926704 . This is a "MORIN AETNA INDIVIDUAL #" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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