Basic Information
Provider Information | |||||||||
NPI: | 1528038577 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VALLEY HEALTH SYSTEMS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VALLEY HEALTH WAYNE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2585 3RD AVE | ||||||||
Address2: |   | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257031642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046971396 | ||||||||
FaxNumber: | 3046972086 | ||||||||
Practice Location | |||||||||
Address1: | 42 MCGINNIS DR | ||||||||
Address2: |   | ||||||||
City: | WAYNE | ||||||||
State: | WV | ||||||||
PostalCode: | 25570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042725136 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2006 | ||||||||
LastUpdateDate: | 03/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUBECK | ||||||||
AuthorizedOfficialFirstName: | MARY-BETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE / CFO | ||||||||
AuthorizedOfficialTelephone: | 3045253334 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |   | 103T00000X |   | WV | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   | 122300000X |   | WV | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   | 363A00000X |   | WV | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 207Q00000X | 13536 | WV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207W00000X |   | WV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   | 363LF0000X |   | WV | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QF0400X |   | WV | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 2752552 | 05 | OH |   | MEDICAID | CJ2698 | 01 | WV | RR MEDICARE GROUP | OTHER | 0097245 | 05 | OH |   | MEDICAID | 0022945001 | 05 | WV |   | MEDICAID | 614938700 | 01 | WV | BLACK LUNG | OTHER | 65916702 | 05 | KY |   | MEDICAID | 6593967000 | 05 | KY |   | MEDICAID |