1467090449 NPI number — POTOMAC VALLEY HOSPITAL OF W VA , INC

Table of content: (NPI 1467090449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467090449 NPI number — POTOMAC VALLEY HOSPITAL OF W VA , INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POTOMAC VALLEY HOSPITAL OF W VA , 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:
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:
1467090449
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1370 JOHNSON AVE STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26330-1492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
681-342-3453
Provider Business Mailing Address Fax Number:
304-842-2333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PIN OAK LN STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEYSER
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26726-5908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-597-3790
Provider Business Practice Location Address Fax Number:
304-597-3564
Provider Enumeration Date:
12/20/2019

Additional Information

Authorized Official

Authorized Official Last Name:
WELLS
Authorized Official First Name:
SUE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
SENIOR DIRECTOR OF CLINIC OPERATION
Authorized Official Telephone Number:
304-597-3525

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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