Basic Information
| Provider Information | |||||||||
| NPI: | 1386699197 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SELBY GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SWING BED UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1106 COLEGATE DR | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405682048 | ||||||||
| FaxNumber: | 7405682094 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 COLEGATE DR | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405682040 | ||||||||
| FaxNumber: | 7405682089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | PAIGE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7405682000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SELBY GENERAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 7943257 | 05 | OH | MEDICAID | 0001482000 | 05 | WV | MEDICAID |