Basic Information
| Provider Information | |||||||||
| NPI: | 1871684324 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTGOMERY GENERAL HOSPITAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270 | ||||||||
| Address2: | 401 SIXTH AVENUE | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251360270 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 401 SIXTH AVENUE | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044425151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | GAY | ||||||||
| AuthorizedOfficialFirstName: | VICKIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3044425151 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 72 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0001386001 | 05 | WV | MEDICAID |