Basic Information
| Provider Information | |||||||||
| NPI: | 1841291960 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRINCETON MEMORIAL HOSPITAL COMPANY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPRINGFIELD CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | RR 1 BOX 101A | ||||||||
| Address2: | |||||||||
| City: | LINDSIDE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249519612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047534332 | ||||||||
| FaxNumber: | 3047534334 | ||||||||
| Practice Location | |||||||||
| Address1: | JAMES MONROE DR AND US RT 219 | ||||||||
| Address2: | |||||||||
| City: | LINDSIDE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 24951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047534332 | ||||||||
| FaxNumber: | 3047534334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3044253203 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NHA CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 126 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0010087000 | 05 | WV | MEDICAID |