Basic Information
| Provider Information | |||||||||
| NPI: | 1194829374 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF SISTERSVILLE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SWING BED UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | SISTERSVILLE GENERAL HOSPITAL | ||||||||
| Address2: | 314 S WELLS ST | ||||||||
| City: | SISTERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261751098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046522611 | ||||||||
| FaxNumber: | 3046521448 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 S WELLS ST | ||||||||
| Address2: | |||||||||
| City: | SISTERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261751098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046522611 | ||||||||
| FaxNumber: | 3046521448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHADOCK | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | AO | ||||||||
| AuthorizedOfficialTelephone: | 3046522611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SISTERSVILLE GENERAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 0002178000 | 05 | WV | MEDICAID |