Basic Information
Provider Information | |||||||||
NPI: | 1245839802 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARIETTA MEMORIAL HOSPITAL OF TYLER COUNTY INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | C/O PAUL WESTBORCK | ||||||||
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: | 10/23/2020 | ||||||||
LastUpdateDate: | 10/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WESTBROCK | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP, LEGAL AFFAIRS | ||||||||
AuthorizedOfficialTelephone: | 7403741581 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MARIETTA MEMORIAL HOSPITAL OF TYLER COUNTY INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X |   |   | Y |   | Agencies | Hospice Care, Community Based |   |
No ID Information.