Healthcare Provider Details

I. General information

NPI: 1619410693
Provider Name (Legal Business Name): SUMMERSVILLE OUTPATIENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 PROFESSIONAL PARK DR
SUMMERSVILLE WV
26651-2018
US

IV. Provider business mailing address

400 FAIRVIEW HEIGHTS RD
SUMMERSVILLE WV
26651-9308
US

V. Phone/Fax

Practice location:
  • Phone: 304-883-2380
  • Fax: 304-872-6854
Mailing address:
  • Phone: 304-883-0220
  • Fax: 304-872-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH KINCELL
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 304-883-0220