Basic Information
| Provider Information | |||||||||
| NPI: | 1568616605 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF SISTERSVILLE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SISTERSVILLE GENERAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 314 S WELLS ST | ||||||||
| Address2: | |||||||||
| City: | SISTERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261751098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046522611 | ||||||||
| FaxNumber: | 3046521448 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 S WELLS ST | ||||||||
| Address2: | |||||||||
| City: | SISTERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261751098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046522611 | ||||||||
| FaxNumber: | 3046521448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2008 | ||||||||
| LastUpdateDate: | 11/14/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOWTHER | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | KEITH | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3044472501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC0050X | 117 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0002178002 | 05 | WV | MEDICAID |