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General NPI Number Information
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NPI Number | 1922197573
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Entity Type | Organization
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Legal Business Name | SOUTH HARRISON FAMILY MEDICINE
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 12/05/2011
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Provider Practice Location Address
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Address Line | 2324 HAWK HIGHWAY
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City | LOST CREEK
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State | WV
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Zip | 26385-9707
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Country | US
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Telephone | 304-745-3200
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Fax | 304-745-4068
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Provider Business Mailing Address
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Address Line | 2324 HAWK HIGHWAY
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City | LOST CREEK
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State | WV
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Zip | 26385-9707
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Country | US
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Telephone | 304-745-3200
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Fax | 304-745-4068
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JO ANN LONGENECKER
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Credential | MD
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Telephone | 304-745-3200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 15551
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License Number State | WV
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