Healthcare Provider Details

I. General information

NPI: 1669633962
Provider Name (Legal Business Name): STONEWALL JACKSON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 HOSPITAL PLZ SUITE 103
WESTON WV
26452-8552
US

IV. Provider business mailing address

230 HOSPITAL PLZ
WESTON WV
26452-8558
US

V. Phone/Fax

Practice location:
  • Phone: 304-269-3108
  • Fax: 304-269-3109
Mailing address:
  • Phone: 304-269-8000
  • Fax: 304-269-8090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20690
License Number StateWV

VIII. Authorized Official

Name: MR. DAVID D SHAFFER
Title or Position: ADMINISTRATOR
Credential:
Phone: 304-269-8000