Basic Information
Provider Information | |||||||||
NPI: | 1982974416 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTERN PANHANDLE MENTAL HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EASTRIDGE HEALTH SYSTEMS, INC. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 235 S WATER ST | ||||||||
Address2: |   | ||||||||
City: | MARTINSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 254014241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042638954 | ||||||||
FaxNumber: | 3042640763 | ||||||||
Practice Location | |||||||||
Address1: | 235 S WATER ST | ||||||||
Address2: |   | ||||||||
City: | MARTINSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 254014241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042638954 | ||||||||
FaxNumber: | 3042640763 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2011 | ||||||||
LastUpdateDate: | 01/05/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MACOM | ||||||||
AuthorizedOfficialFirstName: | G | ||||||||
AuthorizedOfficialMiddleName: | PAUL | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/ CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3042638954 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1022-6441 | WV | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 0023817000 | 05 | WV |   | MEDICAID | 0023817001 | 05 | WV |   | MEDICAID | 0023817002 | 05 | WV |   | MEDICAID | 3810012620 | 05 | WV |   | MEDICAID |