Healthcare Provider Details

I. General information

NPI: 1346341716
Provider Name (Legal Business Name): WESTERN MARYLAND HEALTH SYSTEM CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 HUNT CLUB DR
RIDGELEY WV
26753-7567
US

IV. Provider business mailing address

45 HUNT CLUB DR
RIDGELEY WV
26753-7567
US

V. Phone/Fax

Practice location:
  • Phone: 304-726-4501
  • Fax: 304-726-4051
Mailing address:
  • Phone: 304-726-4501
  • Fax: 304-726-4051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY S REPAC
Title or Position: SR VP CFO
Credential:
Phone: 240-964-8003