1487675336 NPI number — BLUEFIELD MENTAL HEALTH CENTER, PC

Table of content: (NPI 1487675336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487675336 NPI number — BLUEFIELD MENTAL HEALTH CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEFIELD MENTAL HEALTH CENTER, PC
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:
1487675336
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5823 WINNBROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-7894
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-952-8637
Provider Business Mailing Address Fax Number:
866-239-0601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 COURTHOUSE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24740-2421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-952-8637
Provider Business Practice Location Address Fax Number:
866-239-0601
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIAZ
Authorized Official First Name:
PARVEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
SEC/TREASURER
Authorized Official Telephone Number:
304-952-8637

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  41818 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0201433000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 242366000 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 454028 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 036490 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 379529 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 103632 . This is a "FEDERAL BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 142001400 . This is a "US DEPARTMENT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000507728 . This is a "BCBS WV DR.RIAZ" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001708620 . This is a "BCBS WV GROUP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0116701000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7116934 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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