1366440661 NPI number — DR. SOPHIA A SIBOLD D.O.

Table of content: DR. SOPHIA A SIBOLD D.O. (NPI 1366440661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366440661 NPI number — DR. SOPHIA A SIBOLD D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIBOLD
Provider First Name:
SOPHIA
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMMS
Provider Other First Name:
SOPHIA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366440661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HEALTH CENTER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNION
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24983-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-772-3064
Provider Business Mailing Address Fax Number:
304-772-3296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HEALTH CENTER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNION
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24983-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-772-3064
Provider Business Practice Location Address Fax Number:
304-772-3296
Provider Enumeration Date:
07/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2102 , 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: 176557 . This is a "ANTHEM BC/BS-UNION" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: P00206497 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 5611053 . This is a "AETNA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: VAA104451 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 176558 . This is a "PETERSTOWN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001714321 . This is a "BC/BS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810001719 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8130658 . This is a "MAMSI" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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