Basic Information
| Provider Information | |||||||||
| NPI: | 1083943484 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANTAGE HEALTH & WELLNESS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 699 BURROUGHS ST | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265053361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042259355 | ||||||||
| FaxNumber: | 3042259358 | ||||||||
| Practice Location | |||||||||
| Address1: | 699 BURROUGHS ST | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265053361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042259355 | ||||||||
| FaxNumber: | 3042259358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2009 | ||||||||
| LastUpdateDate: | 11/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | TREMBUSH | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/OPERATOR | ||||||||
| AuthorizedOfficialTelephone: | 3042259355 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2330 | WV | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 111N00000X | 769 | WV | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 6371820001 | 01 | CIGNA GOVERNMENT SERVICES | OTHER | 11451727 | 01 | WV | CAQH | OTHER | 3810003266 | 05 | WV | MEDICAID | 271821 | 01 | WV | CARELINK | OTHER | 7254278 | 01 | WV | AETNA | OTHER | 5642046 | 01 | WV | FIRST HEALTH | OTHER | P00337891 | 01 | WV | RAIL ROAD MEDICARE | OTHER |