=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578733655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNITED HOSPITAL CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2008
-----------------------------------------------------
Last Update Date | 11/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 527 MEDICAL PARK DR STE 401
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26330-9010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 681-342-3570
-----------------------------------------------------
Fax | 681-342-3575
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 527 MEDICAL PARK DR STE 401
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26330-9010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 681-342-3570
-----------------------------------------------------
Fax | 681-342-3575
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHAEL TILLMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 681-342-1620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------