Basic Information
| Provider Information | |||||||||
| NPI: | 1144563412 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MD2U WEST VIRGINIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 WHITTINGTON PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402224930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 8556328329 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 MACCORKLE AVE SE # 151 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 8556328329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2013 | ||||||||
| LastUpdateDate: | 04/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | LATTA | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | CIO | ||||||||
| AuthorizedOfficialTelephone: | 5024161851 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MD2U MANAGEMENT LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.