Healthcare Provider Details

I. General information

NPI: 1891176137
Provider Name (Legal Business Name): ST GEORGE MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 TUCKER VALLEY SCHOOL RD
HAMBLETON WV
26269-8052
US

IV. Provider business mailing address

6420 HOLLY MEADOWS RD
PARSONS WV
26287-8055
US

V. Phone/Fax

Practice location:
  • Phone: 304-478-3339
  • Fax:
Mailing address:
  • Phone: 304-478-3339
  • Fax: 304-478-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL H WAMSLEY JR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 304-478-3339