Basic Information
| Provider Information | |||||||||
| NPI: | 1346205069 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMONWEALTH OF VIRGINIA WESTERN STATE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2500 | ||||||||
| Address2: | 1301 RICHMOND RD. | ||||||||
| City: | STAUNTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 244022500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403328200 | ||||||||
| FaxNumber: | 5403328197 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 RICHMOND ROAD | ||||||||
| Address2: | |||||||||
| City: | STAUNTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 244019146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403328200 | ||||||||
| FaxNumber: | 5403328197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 11/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | BARBER | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | HOSPITAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5403328200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 010064830 | 05 | VA | MEDICAID | 0000000007816 | 01 | VA | ANTHEM BLUE CROSS | OTHER | 004941063 | 05 | VA | MEDICAID |