Basic Information
| Provider Information | |||||||||
| NPI: | 1689636821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERVA | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 12TH STREET EXT | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044315168 | ||||||||
| FaxNumber: | 3044877835 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 NEW HOPE RD STE 7 | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044317200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 14198 | WV | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0091117000 | 05 | WV | MEDICAID |