Healthcare Provider Details

I. General information

NPI: 1750378345
Provider Name (Legal Business Name): SUMMERSVILLE OUT PATIENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FAIRVIEW HEIGHTS RD
SUMMERSVILLE WV
26651-9308
US

IV. Provider business mailing address

400 FAIRVIEW HEIGHTS RD
SUMMERSVILLE WV
26651-9308
US

V. Phone/Fax

Practice location:
  • Phone: 304-872-5124
  • Fax: 304-872-0675
Mailing address:
  • Phone: 304-872-5124
  • Fax: 304-872-0675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number51D0933140
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number61
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61
License Number StateWV

VIII. Authorized Official

Name: DEBBIE HILL
Title or Position: CEO
Credential: MBA
Phone: 304-872-8402