Basic Information
Provider Information | |||||||||
NPI: | 1962540773 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WILLIAMSON MEMORIAL HOSPITAL LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WILLIAMSON PHYSICIANS GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1958 | ||||||||
Address2: |   | ||||||||
City: | WILLIAMSON | ||||||||
State: | WV | ||||||||
PostalCode: | 256611958 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3048996118 | ||||||||
FaxNumber: | 3042350538 | ||||||||
Practice Location | |||||||||
Address1: | 859 ALDERSON ST | ||||||||
Address2: |   | ||||||||
City: | WILLIAMSON | ||||||||
State: | WV | ||||||||
PostalCode: | 256613215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042350466 | ||||||||
FaxNumber: | 3042350536 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2007 | ||||||||
LastUpdateDate: | 05/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUNYON | ||||||||
AuthorizedOfficialFirstName: | SANDRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN PRACTICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3048996118 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   | WV | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 0001235002 | 05 | WV |   | MEDICAID |