Basic Information
| Provider Information | |||||||||
| NPI: | 1013372531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTGOMERY GEN CAHGRP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251362116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044425151 | ||||||||
| FaxNumber: | 3044427494 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251362116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044425151 | ||||||||
| FaxNumber: | 3044427494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2015 | ||||||||
| LastUpdateDate: | 02/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | MURRAY | ||||||||
| AuthorizedOfficialFirstName: | SHERRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3044421246 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MONTGOMERY GENERAL HOSPITAL, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810001437 | 05 | WV | MEDICAID |