Basic Information
Provider Information | |||||||||
NPI: | 1275701674 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTRIDGE HEALTH SYSTEMS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 235 S WATER ST | ||||||||
Address2: |   | ||||||||
City: | MARTINSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 254014241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042638954 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 235 S WATER ST | ||||||||
Address2: |   | ||||||||
City: | MARTINSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 254014241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042638954 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2008 | ||||||||
LastUpdateDate: | 02/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COGLE | ||||||||
AuthorizedOfficialFirstName: | MONICA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHILDREN'S OUTREACH LIAISON | ||||||||
AuthorizedOfficialTelephone: | 3042638954 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LGSW, MSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | BP00939896 | WV | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.