Basic Information
| Provider Information | |||||||||
| NPI: | 1831378504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. MARY'S MEDICAL MANAGEMENT HIGHLAWN LAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 88 | ||||||||
| Address2: | |||||||||
| City: | WHITE SULPHUR SPRINGS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249860088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045365030 | ||||||||
| FaxNumber: | 3045365031 | ||||||||
| Practice Location | |||||||||
| Address1: | 2828 1ST AVE | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043997565 | ||||||||
| FaxNumber: | 3043997568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2007 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | LIESEN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | LABORATORY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3043997565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. MARY'S MEDICAL MANAGEMENT | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 3810009673 | 05 | WV | MEDICAID |