Basic Information
| Provider Information | |||||||||
| NPI: | 1235754581 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | USA VASCULAR CENTER OF MORGANTOWN PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600650791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475938460 | ||||||||
| FaxNumber: | 2242354652 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 SUNCREST TOWNE CENTRE | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475938460 | ||||||||
| FaxNumber: | 2242354652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2020 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALMEDA | ||||||||
| AuthorizedOfficialFirstName: | AMI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2243180118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.