Basic Information
Provider Information | |||||||||
NPI: | 1235311044 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRINCETON COMMUNITY HOSPITAL ASSOCIATION, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PCH BEHAVIORAL MEDICINE UNIT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 122 12TH STREET EXTENSION | ||||||||
Address2: |   | ||||||||
City: | PRINCETON | ||||||||
State: | WV | ||||||||
PostalCode: | 247402352 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044877000 | ||||||||
FaxNumber: | 3044877370 | ||||||||
Practice Location | |||||||||
Address1: | 122 12TH STREET EXT | ||||||||
Address2: |   | ||||||||
City: | PRINCETON | ||||||||
State: | WV | ||||||||
PostalCode: | 247402352 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044877000 | ||||||||
FaxNumber: | 3044877370 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2007 | ||||||||
LastUpdateDate: | 12/04/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SINICROPE | ||||||||
AuthorizedOfficialFirstName: | FRANK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3044877263 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PRINCETON COMMUNITY HOSPITAL ASSOCIATION, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 104 | WV | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 0001111002 | 05 | WV |   | MEDICAID |