=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770581118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM R. SHARPE, JR. HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2005
-----------------------------------------------------
Last Update Date | 09/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 936 SHARPE HOSPITAL RD
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26452-8550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-269-1210
-----------------------------------------------------
Fax | 304-269-6235
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 936 SHARPE HOSPITAL RD
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26452-8550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-269-1210
-----------------------------------------------------
Fax | 304-269-6235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | BRYAN GUSTKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-269-1210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number | EXEMPT
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------