Basic Information
Provider Information | |||||||||
NPI: | 1649277476 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HEALTH ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JACKSON GENERAL HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 720 | ||||||||
Address2: | 122 PINNELL STREET | ||||||||
City: | RIPLEY | ||||||||
State: | WV | ||||||||
PostalCode: | 252710720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043731477 | ||||||||
FaxNumber: | 3043722749 | ||||||||
Practice Location | |||||||||
Address1: | 122 PINNELL STREET | ||||||||
Address2: |   | ||||||||
City: | RIPLEY | ||||||||
State: | WV | ||||||||
PostalCode: | 252710720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043731477 | ||||||||
FaxNumber: | 3043722749 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 05/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCOY | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
AuthorizedOfficialTelephone: | 3043731475 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 52 | WV | N |   | Hospital Units | Medicare Defined Swing Bed Unit |   | 282NC0060X | 52 | WV | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 3810023822 | 05 | WV |   | MEDICAID | 3910000963 | 05 | WV |   | MEDICAID | 512320 | 01 | WV | SWING BED | OTHER | 51-Z320 | 01 | WV | SWING BED | OTHER | 51U018 | 01 | WV | SWING BED | OTHER | 5100181 | 01 | WV | MEDICARE- ID | OTHER |