Basic Information
| Provider Information | |||||||||
| NPI: | 1417280355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PVH SERFONTEIN OFFICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 236 | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255500236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046751020 | ||||||||
| FaxNumber: | 3046755893 | ||||||||
| Practice Location | |||||||||
| Address1: | 2418 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255501528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046756835 | ||||||||
| FaxNumber: | 3046756849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2009 | ||||||||
| LastUpdateDate: | 09/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | SCHAUER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO, VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3046754340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PLEASANT VALLEY HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 21178 | WV | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810001774 | 05 | WV | MEDICAID | 2548390 | 05 | OH | MEDICAID |