Basic Information
| Provider Information | |||||||||
| NPI: | 1710203419 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF SISTERSVILLE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SISTERSVILLE RURAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 305 CLAY ST | ||||||||
| Address2: | |||||||||
| City: | SISTERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044472038 | ||||||||
| FaxNumber: | 3044473990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2010 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHADOCK | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | AO | ||||||||
| AuthorizedOfficialTelephone: | 3046522611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 513412 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 3810018439 | 05 | WV | MEDICAID |