Basic Information
| Provider Information | |||||||||
| NPI: | 1518275627 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY HEALTH SYSTEMS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VALLEY HEALTH SOUTHSIDE ELEMENTARY HEALTH CENTER | ||||||||
| 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: | 930 2ND STREET | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045285168 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2010 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEINBERGER | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3045253334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 3810018947 | 05 | WV | MEDICAID |