Basic Information
| Provider Information | |||||||||
| NPI: | 1083805790 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JACKSON GENERAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 PINNELL ST | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252719101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043722731 | ||||||||
| FaxNumber: | 3043722749 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 PINNELL ST | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252719101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043722731 | ||||||||
| FaxNumber: | 3043722749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 10/16/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3043722731 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 52 | WV | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 0001320007 | 05 | WV | MEDICAID | 3810023822 | 05 | WV | MEDICAID |