Basic Information
| Provider Information | |||||||||
| NPI: | 1043477235 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JACKSON GENERAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720 | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252710720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043731519 | ||||||||
| FaxNumber: | 3043731598 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 PINNELL ST | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252719101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043722731 | ||||||||
| FaxNumber: | 3043731598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREENE | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3043731507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3910000963 | 01 | WV | MEDICAID-ID | OTHER |