Basic Information
| Provider Information | |||||||||
| NPI: | 1093883324 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAINELLE MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEADOW BRIDGE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 MEADOW BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MEADOW BRIDGE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259769655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044847755 | ||||||||
| FaxNumber: | 3044846205 | ||||||||
| Practice Location | |||||||||
| Address1: | 1502 MEADOW BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MEADOW BRIDGE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259769655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044847755 | ||||||||
| FaxNumber: | 3044846205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 10/14/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ATHA-RADER | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3044386188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0035241003 | 05 | WV | MEDICAID |