Basic Information
Provider Information | |||||||||
NPI: | 1801140579 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY HEALTHCARE PHYSICIANS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNIVERSITY URGENT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2500 FOUNDATION WAY | ||||||||
Address2: |   | ||||||||
City: | MARTINSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 254019000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042649202 | ||||||||
FaxNumber: | 3042649042 | ||||||||
Practice Location | |||||||||
Address1: | 912 SOMERSET BLVD | ||||||||
Address2: | STE 102 | ||||||||
City: | CHARLES TOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 25414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3047252273 | ||||||||
FaxNumber: | 3047240053 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2012 | ||||||||
LastUpdateDate: | 01/27/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NAU | ||||||||
AuthorizedOfficialFirstName: | KONRAD | ||||||||
AuthorizedOfficialMiddleName: | C. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3042649202 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 291U00000X |   |   | N |   | Laboratories | Clinical Medical Laboratory |   | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.