Basic Information
Provider Information | |||||||||
NPI: | 1194020677 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VALLEY HEALTH SYSTEMS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VALLEY HEALTH GALLIPOLIS FERRY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1680 | ||||||||
Address2: |   | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257171680 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046971396 | ||||||||
FaxNumber: | 3046972086 | ||||||||
Practice Location | |||||||||
Address1: | 15167 HUNTINGTON ROAD | ||||||||
Address2: |   | ||||||||
City: | GALLIPOLIS FERRY | ||||||||
State: | WV | ||||||||
PostalCode: | 25515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046755725 | ||||||||
FaxNumber: | 3046972086 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2011 | ||||||||
LastUpdateDate: | 03/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUBECK | ||||||||
AuthorizedOfficialFirstName: | MARY-BETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE / CFO | ||||||||
AuthorizedOfficialTelephone: | 3045253334 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QF0400X |   | WV | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 3810021314 | 05 | WV |   | MEDICAID | 0072821 | 05 | OH |   | MEDICAID | 0097214 | 05 | OH |   | MEDICAID |