1922155217 NPI number — ST. MARY'S MEDICAL MANAGEMENT, LLC

Table of content: (NPI 1922155217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922155217 NPI number — ST. MARY'S MEDICAL MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. MARY'S MEDICAL MANAGEMENT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922155217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARBOURSVILLE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25504-4190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-908-9201
Provider Business Mailing Address Fax Number:
304-935-3334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-526-1234
Provider Business Practice Location Address Fax Number:
304-526-1489
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CAMPBELL
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
304-526-8914

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0201X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001934200 . This is a "BSMT MOUNTAIN STATE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 7100101210 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100073660 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002016965 . This is a "BSMT/ MID LEVEL" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810009673 . This is a "UNISYS / ST MARY'S LAB" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810007944 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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