Basic Information
| Provider Information | |||||||||
| NPI: | 1366415143 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANT MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GRANT MEMORIAL HOSPITAL HOMEHEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1019 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 268471019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042571026 | ||||||||
| FaxNumber: | 3042571932 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042575815 | ||||||||
| FaxNumber: | 3042572093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MICHAELS | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3042575802 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0001375002 | 05 | WV | MEDICAID |