1215097613 NPI number — BROADDUS HOSPITAL ASSOCIATION, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215097613 NPI number — BROADDUS HOSPITAL ASSOCIATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADDUS HOSPITAL ASSOCIATION, INC.
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:
6
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:
1215097613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
#5 HEALTHCARE DRIVE
Provider Second Line Business Mailing Address:
P.O. BOX 930
Provider Business Mailing Address City Name:
PHILIPPI
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-457-8535
Provider Business Mailing Address Fax Number:
304-457-1516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
#5 HEALTHCARE DRIVE
Provider Second Line Business Practice Location Address:
MANSFIELD HILL
Provider Business Practice Location Address City Name:
PHILIPPI
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-457-8535
Provider Business Practice Location Address Fax Number:
304-457-1516
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOULD
Authorized Official First Name:
DANA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
304-457-1760

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  96 , 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: 0002167001 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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