1548446099 NPI number — MORGANTOWN PLASTIC SURGERY ASSOCIATES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548446099 NPI number — MORGANTOWN PLASTIC SURGERY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MORGANTOWN PLASTIC SURGERY ASSOCIATES
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:
6
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:
1548446099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 COOMBS FARM DR
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26508-1121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-777-4677
Provider Business Mailing Address Fax Number:
304-777-4679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 COOMBS FARM DR
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26508-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-777-4677
Provider Business Practice Location Address Fax Number:
304-777-4679
Provider Enumeration Date:
01/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
BECKY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
304-777-4677

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  21436 , 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)





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