MEDICARE: POTOMAC VALLEY HOSPITAL OF W VA , INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1902444987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POTOMAC VALLEY HOSPITAL OF W VA , INC

Provider Business Mailing Address
First Line	:	1370 JOHNSON AVE STE 102
Second Line	:
City	:	BRIDGEPORT
State	:	WV
Zip	:	26330-1492
Country	:	US
Telephone Number	:	681-342-3453
Fax Number	:	304-824-4233

Provider Business Practice Location Address
First Line	:	10261 FRANKFORT HWY
Second Line	:
City	:	FORT ASHBY
State	:	WV
Zip	:	26719-4533
Country	:	US
Telephone Number	:	304-597-3600
Fax Number	:	304-285-3963

Authorized Official
Title or Position	:	SENIOR DIRECTOR OF CLINIC OPERATION
Name	:	SUE A WELLS
Credential	:
Telephone Number	:	304-597-3525

Provider Enumeration Date	:	12/20/2019
Last Update Date	:	12/20/2019

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