Basic Information
| Provider Information | |||||||||
| NPI: | 1790001113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042933091 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265061200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045984800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2010 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD453849 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25019 | WV | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 103009586 | 05 | PA | MEDICAID |