Basic Information
| Provider Information | |||||||||
| NPI: | 1477885044 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY HEALTH SYSTEMS INC | ||||||||
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| OtherOrganizationName: | VALLEY HEALTH UPPER KANAWHA DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1680 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257171680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046971396 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 ALEXANDER STREET | ||||||||
| Address2: | P.O. BOX F | ||||||||
| City: | CEDAR GROVE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045951770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2010 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | WEINBERGER | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3045253334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 3400 | WV | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 3810017446 | 05 | WV | MEDICAID |