Basic Information
| Provider Information | |||||||||
| NPI: | 1194287565 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF WEST VIRGINIA CONCORD UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247121000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043845608 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 VERMILLION ST | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247129027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043847325 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2019 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | GALATIC | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF BUSINESS & FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 3043845190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2255A2300X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QS1000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
No ID Information.