Healthcare Provider Details

I. General information

NPI: 1588039242
Provider Name (Legal Business Name): SUMMERSVILLE OUTPATIENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FLORENCE STREET
ANSTED WV
25812
US

IV. Provider business mailing address

400 FAIRVIEW HEIGHTS RD
SUMMERSVILLE WV
26651-9308
US

V. Phone/Fax

Practice location:
  • Phone: 304-883-0220
  • Fax: 304-872-8417
Mailing address:
  • Phone: 304-883-0220
  • Fax: 304-872-8417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateWV

VIII. Authorized Official

Name: MARK LOVELL
Title or Position: CFO
Credential:
Phone: 304-872-2891