1487858775 NPI number — DR. JENNY LYNN CROSS M.D.

Table of content: DR. JENNY LYNN CROSS M.D. (NPI 1487858775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487858775 NPI number — DR. JENNY LYNN CROSS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROSS
Provider First Name:
JENNY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1487858775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 GORMAN AVENUE
Provider Second Line Business Mailing Address:
DAVIS MEDICAL CENTER; DBA TYGART VALLEY MEDICAL SPECIAL
Provider Business Mailing Address City Name:
ELKINS
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-637-6302
Provider Business Mailing Address Fax Number:
304-637-6307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 GORMAN AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
ELKINS
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26241-3082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-637-6302
Provider Business Practice Location Address Fax Number:
304-637-6307
Provider Enumeration Date:
06/12/2007

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: 207Y00000X , with the licence number:  21597 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207YX0602X , with the licence number: 21597 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3810009381 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21597 . This is a "WV MEDICAL LICENSE NUMER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: P00423429 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001975500 . This is a "MOUNTAIN STATE BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: WV21597 . This is a "HEALTH PLAN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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