Basic Information
| Provider Information | |||||||||
| NPI: | 1083617823 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHENANDOAH VALLEY MEDICAL SYSTEM, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1146 | ||||||||
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| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254022890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042634999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 99 TAVERN RD | ||||||||
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| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254012890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042634999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HASSING | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3042634999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0035217000 | 05 | WV | MEDICAID |