Basic Information
| Provider Information | |||||||||
| NPI: | 1184233454 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. MARY'S HIMG, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5170 US ROUTE 60 EAST | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045284600 | ||||||||
| FaxNumber: | 3047333143 | ||||||||
| Practice Location | |||||||||
| Address1: | 5170 US ROUTE 60 EAST | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045284600 | ||||||||
| FaxNumber: | 3047333143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2020 | ||||||||
| LastUpdateDate: | 07/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | MORGAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3045284600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST MARYS MEDICAL CENTER, INC | ||||||||
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| NPICertificationDate: | 07/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207UN0901X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.