Basic Information
| Provider Information | |||||||||
| NPI: | 1306066592 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH MANAGEMENT ASSOCIATES OF WV | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WILLIAMSON PHYSICIANS GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1958 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256611958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042350466 | ||||||||
| FaxNumber: | 3042350536 | ||||||||
| Practice Location | |||||||||
| Address1: | 859 ALDERSON ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256613215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042350466 | ||||||||
| FaxNumber: | 3042350536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3042350466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 65942377 | 05 | KY | MEDICAID |