Basic Information
| Provider Information | |||||||||
| NPI: | 1821489469 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRAXTON COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRAXTON COUNTY MEMORIAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOYLMAN DR | ||||||||
| Address2: | |||||||||
| City: | GASSAWAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266249318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043645156 | ||||||||
| FaxNumber: | 3043645809 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOYLMAN DR | ||||||||
| Address2: | |||||||||
| City: | GASSAWAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266249318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043645156 | ||||||||
| FaxNumber: | 3043645809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2015 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | KNIGHT | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | DAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3043641128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC0050X | 3 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital |
ID Information
| ID | Type | State | Issuer | Description | 4006002000 | 05 | WV | MEDICAID |