1689069700 NPI number — DR. JEREMY DANIEL HUSTEAD M.D.

Table of content: DR. JEREMY DANIEL HUSTEAD M.D. (NPI 1689069700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689069700 NPI number — DR. JEREMY DANIEL HUSTEAD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUSTEAD
Provider First Name:
JEREMY
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1689069700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MEDICAL CENTER DRIVE, ROOM 4601
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26506-8121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-293-5323
Provider Business Mailing Address Fax Number:
304-293-8724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MEDICAL CENTER DRIVE
Provider Second Line Business Practice Location Address:
ROOM 4601
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26506-8121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-293-5323
Provider Business Practice Location Address Fax Number:
304-293-8724
Provider Enumeration Date:
04/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084A0401X , with the licence number:  27683 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 27683 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0802X , with the licence number: 27683 , 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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