Basic Information
| Provider Information | |||||||||
| NPI: | 1144303678 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUKE'S PRINCETON LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST LUKE'S PRICETON LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 SOUTHVIEW DR | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247014317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043272900 | ||||||||
| FaxNumber: | 3043272989 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 SOUTHVIEW DR | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247014317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043272900 | ||||||||
| FaxNumber: | 3043272989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALDRIDGE | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CRNA | ||||||||
| AuthorizedOfficialTelephone: | 3043272900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0068965000 | 05 | WV | MEDICAID |