Healthcare Provider Details

I. General information

NPI: 1922295062
Provider Name (Legal Business Name): BROADDUS HOSPITAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#1 HEALTH CARE DRIVE
PHILIPPI WV
26416
US

IV. Provider business mailing address

#1 HEALTH CARE DRIVE
PHILIPPI WV
26416
US

V. Phone/Fax

Practice location:
  • Phone: 304-457-1760
  • Fax: 304-457-3781
Mailing address:
  • Phone: 304-457-1760
  • Fax: 304-457-3781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number StateWV

VIII. Authorized Official

Name: DANA L GOULD
Title or Position: CEO
Credential:
Phone: 304-457-8155