Basic Information
| Provider Information | |||||||||
| NPI: | 1346523206 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POCAHONTAS MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | POCAHONTAS MEMORIAL HOSPITAL MEDICAL PRACTICE RHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 DUNCAN RD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 24924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047996200 | ||||||||
| FaxNumber: | 3047996636 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 DUNCAN RD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 24924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047996200 | ||||||||
| FaxNumber: | 3047996636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2011 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STARCHER | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | RUTH | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 3047997400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 16 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 3810023879 | 05 | WV | MEDICAID |