Provider Demographics
NPI:1902994577
Name:MID-OHIO VALLEY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MID-OHIO VALLEY MEDICAL GROUP, INC.
Other - Org Name:MOVMG LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RANDAL
Authorized Official - Last Name:HEAVNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-485-3303
Mailing Address - Street 1:PO BOX 1669
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26102-1669
Mailing Address - Country:US
Mailing Address - Phone:304-485-3300
Mailing Address - Fax:304-485-3317
Practice Address - Street 1:800 GRAND CENTRAL MALL
Practice Address - Street 2:SUITE 4
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-4131
Practice Address - Country:US
Practice Address - Phone:304-485-3300
Practice Address - Fax:304-485-3317
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-OHIO VALLEY MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6703034000Medicaid
WV9307481Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER