1043397110 NPI number — GRANT COUNTY BOARD OF HEALTH

Table of content: WILHELMINA MATIENZO SANTIAGO M.D. (NPI 1548496474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043397110 NPI number — GRANT COUNTY BOARD OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANT COUNTY BOARD OF HEALTH
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:
GRANT COUNTY HEALTH DEPARTMENT
Provider Other Organization Name Type Code:
3
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:
1043397110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 608
Provider Second Line Business Mailing Address:
739 NORTH FORK HIGHWAY
Provider Business Mailing Address City Name:
PETERSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26847-0608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-257-4922
Provider Business Mailing Address Fax Number:
304-257-2422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
739 NORTH FORK HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-257-4922
Provider Business Practice Location Address Fax Number:
304-257-2422
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAHN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
LOCAL HEALTH OFFICER
Authorized Official Telephone Number:
304-257-4922

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , 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)

  • Identifier: 0091234000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0021284000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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