Provider First Line Business Practice Location Address: 
1 MEDICAL CENTER DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MORGANTOWN
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26506-1200
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-598-4148
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/26/2018