Basic Information
| Provider Information | |||||||||
| NPI: | 1942432687 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY'S HOSPITALIST SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5170 US RT 60 EAST | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045284600 | ||||||||
| FaxNumber: | 3047333143 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 1ST AVE RM 1025 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043997484 | ||||||||
| FaxNumber: | 3043997579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2009 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | MORGAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3045284600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST MARY'S MEDICAL MANAGEMENT, LLC | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207R00000X | WV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3012751 | 05 | OH | MEDICAID | 613918805 | 01 | WV | BLACK LUNG/FECA | OTHER | 3810016162 | 05 | WV | MEDICAID | 000000287928 | 01 | OH | UNISON | OTHER |