1114994241 NPI number — MIRIAM C WILPS CRNA

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114994241 NPI number — MIRIAM C WILPS CRNA

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WILPS

Provider First Name:

MIRIAM

Provider Middle Name:

C

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

CRNA

Provider Gender Code:

F

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:

1114994241

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

10/29/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

109 MOUNT WOOD RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

WHEELING

Provider Business Mailing Address State Name:

WV

Provider Business Mailing Address Postal Code:

26003-2632

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

304-233-2455

Provider Business Mailing Address Fax Number:

304-233-6073

Provider First Line Business Practice Location Address:

601 COLLIERS WAY

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

WEIRTON

Provider Business Practice Location Address State Name:

WV

Provider Business Practice Location Address Postal Code:

26062-5014

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

304-797-6543

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

03/08/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 367500000X , with the licence number:  RN220746L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 367500000X , with the licence number: 54904 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1062424 . This is a "WV WORKERS' COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 270052997004 . This is a "TRICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 001964246 . This is a "MSBCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 0069251000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
• Identifier: 101465372 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 27005299701 . This is a "BRICKSTREET" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 27005299700 . This is a "WORKERS COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 001718477 . This is a "MSBCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 0207026000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
• Identifier: DA0096 . This is a "RR MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 001706470 . This is a "MSBCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".