MEDICARE: TUG RIVER HEALTH ASSOCIATION, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)	031000	WV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CN3563	OTHER	WV	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	001706659	OTHER	WV	MS BCBS

General Provider Information

NPI Number	:	1831273945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TUG RIVER HEALTH ASSOCIATION, INC

Provider Business Mailing Address
First Line	:	ROUTE 103 SUPPLY STREET, PO BOX 507
Second Line	:
City	:	GARY
State	:	WV
Zip	:	24836
Country	:	US
Telephone Number	:	304-448-2101
Fax Number	:	304-448-3217

Provider Business Practice Location Address
First Line	:	10 MAIN STREET
Second Line	:
City	:	NORTHFORK
State	:	WV
Zip	:	24868
Country	:	US
Telephone Number	:	304-862-2588
Fax Number	:	304-862-2244

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MRS. KIM HARRIS
Credential	:
Telephone Number	:	304-448-2101

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	12/06/2018

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