Basic Information
Provider Information | |||||||||
NPI: | 1194762278 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GALEN-MED, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLINCH VALLEY MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2949 WEST FRONT ST | ||||||||
Address2: |   | ||||||||
City: | RICHLANDS | ||||||||
State: | VA | ||||||||
PostalCode: | 246412099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2765966000 | ||||||||
FaxNumber: | 2765966009 | ||||||||
Practice Location | |||||||||
Address1: | 2949 WEST FRONT ST | ||||||||
Address2: |   | ||||||||
City: | RICHLANDS | ||||||||
State: | VA | ||||||||
PostalCode: | 246412099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2765966000 | ||||||||
FaxNumber: | 2765966009 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARALSON | ||||||||
AuthorizedOfficialFirstName: | BOB | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2765966672 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 756 | 01 | VA | WELLPOINT VA/BLUE CROSS | OTHER |