Healthcare Provider Details

I. General information

NPI: 1205268414
Provider Name (Legal Business Name): HEDGESVILLE HEALTHCARE CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 HEDGESVILLE RD STE H
HEDGESVILLE WV
25427-6704
US

IV. Provider business mailing address

3790 HEDGESVILLE RD STE H
HEDGESVILLE WV
25427-6704
US

V. Phone/Fax

Practice location:
  • Phone: 304-754-7160
  • Fax: 304-754-7244
Mailing address:
  • Phone: 304-754-7160
  • Fax: 304-754-7244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number23659
License Number StateWV

VIII. Authorized Official

Name: DR. JUSTIN GLASSFORD
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 304-754-7160