1366759227 NPI number — UNITED HOSPITAL CENTER

Table of content: DR. TRACE HAMILTON RUTHERFORD D.D.S. (NPI 1841366143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366759227 NPI number — UNITED HOSPITAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNITED HOSPITAL CENTER
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:
1366759227
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
527 MEDICAL PARK DR
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26330-9008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-842-1034
Provider Business Mailing Address Fax Number:
304-842-1037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
916 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-1034
Provider Business Practice Location Address Fax Number:
304-842-1037
Provider Enumeration Date:
09/13/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MEADOWS
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CORPORATE COMPLIANCE
Authorized Official Telephone Number:
681-342-1610

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  107 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 107 , 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: 3810018554 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".