=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437426780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMERSVILLE FAMILY MEDICINE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2011
-----------------------------------------------------
Last Update Date | 10/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 MERCHANTS WALK SHOPPING CENTER
-----------------------------------------------------
City | SUMMERSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26651-1901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-645-4043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1049
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24901-4049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RICHARD S TRENBATH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 304-645-4043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 12758
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 12758
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------