Basic Information
| Provider Information | |||||||||
| NPI: | 1083767859 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIAMSTOWN MEDICAL SERVICE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261871615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043757992 | ||||||||
| FaxNumber: | 3043753762 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261871615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043757992 | ||||||||
| FaxNumber: | 3043753762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHREIBER | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | LOUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3043757992 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 676 | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0315555 | 05 | OH | MEDICAID | 0049300000 | 05 | WV | MEDICAID |