Basic Information
| Provider Information | |||||||||
| NPI: | 1730897836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 MARYLAND WAY STE 120 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274993 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4600 HOUSTON RD BLDG 1 | ||||||||
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| City: | FLORENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410424820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592833613 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2022 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | LEGAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 6155775893 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.