Provider Demographics
NPI:1174593065
Name:WEDGEWOOD FAMILY PRACTICE & PSYCHIATRY ASSOCIATES, INC
Entity type:Organization
Organization Name:WEDGEWOOD FAMILY PRACTICE & PSYCHIATRY ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:Z
Authorized Official - Last Name:SINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-599-9400
Mailing Address - Street 1:1197 VAN VOORHIS RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3478
Mailing Address - Country:US
Mailing Address - Phone:304-599-9400
Mailing Address - Fax:304-599-8917
Practice Address - Street 1:1197 VAN VOORHIS RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3478
Practice Address - Country:US
Practice Address - Phone:304-599-9400
Practice Address - Fax:304-599-8917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9182021Medicare PIN
WV9182022Medicare PIN