Basic Information
| Provider Information | |||||||||
| NPI: | 1598763666 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRANT MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1019 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 268471019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042571026 | ||||||||
| FaxNumber: | 3042571932 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 268479566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042571026 | ||||||||
| FaxNumber: | 3042571932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 02/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | MILVET | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3042571026 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 21 | WV | N | Hospital Units | Medicare Defined Swing Bed Unit | 282N00000X | 21 | WV | N | Hospitals | General Acute Care Hospital | 282NC0060X | 21 | WV | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 0001375000 | 05 | WV | MEDICAID | 3810016182 | 05 | WV | MEDICAID |