Basic Information
| Provider Information | |||||||||
| NPI: | 1083694756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY HEALTH SYSTEMS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VALLEY HEALTH FORT GAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2585 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257031642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046971396 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 WAYNE ST | ||||||||
| Address2: | |||||||||
| City: | FORT GAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046485544 | ||||||||
| FaxNumber: | 3046485989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRUBECK | ||||||||
| AuthorizedOfficialFirstName: | MARY-BETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE / CFO | ||||||||
| AuthorizedOfficialTelephone: | 3045253334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 103T00000X | WV | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 122300000X | 2768 | WV | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 207Q00000X | 1744 | WV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | WV | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | WV | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QF0400X | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 65916702 | 05 | KY | MEDICAID | 6593981100 | 05 | KY | MEDICAID | CJ2698 | 01 | WV | RR MEDICARE GROUP | OTHER | 2752543 | 05 | OH | MEDICAID | 61900841 | 05 | KY | MEDICAID | 0035071000 | 05 | WV | MEDICAID | 614938702 | 01 | WV | BLACK LUNG | OTHER |