1063539997 NPI number — JEFFERSON BEHAVIORAL HEALTH SYSTEM

Table of content: (NPI 1063539997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063539997 NPI number — JEFFERSON BEHAVIORAL HEALTH SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON BEHAVIORAL HEALTH SYSTEM
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:
1063539997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 ROSS PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
STEUBENVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43952-2681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-264-7751
Provider Business Mailing Address Fax Number:
740-264-2422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 ROSS PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
STEUBENVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43952-2681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-264-7751
Provider Business Practice Location Address Fax Number:
740-264-2422
Provider Enumeration Date:
03/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHEPOSH
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
740-264-7751

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  0191 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 1308 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 1310 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2488455 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7063 . This is a "MACSIS LEGACY PROVIDER ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0200517 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24-01 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2410733 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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