Basic Information
| Provider Information | |||||||||
| NPI: | 1942200381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWINGHOLM | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1019 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 268471019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042571026 | ||||||||
| FaxNumber: | 3042571932 | ||||||||
| Practice Location | |||||||||
| Address1: | C/O GRANT MEMORIAL HOSPITAL | ||||||||
| Address2: | 1 HOSPITAL DRIVE | ||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042571026 | ||||||||
| FaxNumber: | 3042571932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 59659 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2605108000 | 05 | WV | MEDICAID |