Basic Information
| Provider Information | |||||||||
| NPI: | 1003244690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDICS-SUNCREST PLAZA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WVU MEDICAL CORPORATION DBA UHA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 897 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042857100 | ||||||||
| FaxNumber: | 3042857126 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 VAN VOORHIS RD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265053586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045984830 | ||||||||
| FaxNumber: | 3045984537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2013 | ||||||||
| LastUpdateDate: | 10/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | RUMBLE | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 3043857101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0011526000 | 05 | WV | MEDICAID |