Basic Information
Provider Information | |||||||||
NPI: | 1518966191 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PENDLETON COUNTY FISCAL COURT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 836 4TH AVE | ||||||||
Address2: |   | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257011407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8006764785 | ||||||||
FaxNumber: | 3045224222 | ||||||||
Practice Location | |||||||||
Address1: | 705 W SHELBY ST | ||||||||
Address2: |   | ||||||||
City: | FALMOUTH | ||||||||
State: | KY | ||||||||
PostalCode: | 410401037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8596544321 | ||||||||
FaxNumber: | 8596545047 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2005 | ||||||||
LastUpdateDate: | 04/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERTRAM | ||||||||
AuthorizedOfficialFirstName: | HENRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
AuthorizedOfficialTelephone: | 8596544321 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 1599 | KY | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 0843896 | 05 | OH |   | MEDICAID | 000000039195 | 01 | KY | ANTHEM | OTHER | 55096036 | 05 | KY |   | MEDICAID |