Basic Information
| Provider Information | |||||||||
| NPI: | 1568401461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENBRIER EMERGENCY SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634715 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452634715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882031274 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HOYLMAN DR | ||||||||
| Address2: | |||||||||
| City: | GASSAWAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266249320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043645156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 01/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | DABBS | ||||||||
| AuthorizedOfficialFirstName: | RANDAL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8656931000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001712003 | 01 | WV | WEST VIRGINIA BLUE SHIELD | OTHER | 0207350-000 | 05 | WV | MEDICAID |