1992244081 NPI number — SUMMERSVILLE OUTPATIENT CENTER

Table of content: (NPI 1992244081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992244081 NPI number — SUMMERSVILLE OUTPATIENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMERSVILLE OUTPATIENT CENTER
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:
SUMMERSVILLE PODIATRY CLINIC
Provider Other Organization Name Type Code:
5
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:
1992244081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 FAIRVIEW HEIGHTS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMMERSVILLE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26651-9308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-872-8402
Provider Business Mailing Address Fax Number:
304-872-2080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 PROFFESSIONAL PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26651-2018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-883-2381
Provider Business Practice Location Address Fax Number:
304-883-2383
Provider Enumeration Date:
02/22/2017

Additional Information

Authorized Official

Authorized Official Last Name:
KINCELL
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
REVENUE CYCLE DIRECTOR
Authorized Official Telephone Number:
304-883-0220

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  00315 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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