Provider Demographics
NPI:1023186533
Name:UNITED PHYSICIANS CARE INC
Entity Type:Organization
Organization Name:UNITED PHYSICIANS CARE INC
Other - Org Name:PENNSBORO MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:FORESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-624-4655
Mailing Address - Street 1:686 S PIKE ST
Mailing Address - Street 2:STE A
Mailing Address - City:SHINNSTON
Mailing Address - State:WV
Mailing Address - Zip Code:26431-1043
Mailing Address - Country:US
Mailing Address - Phone:304-624-4655
Mailing Address - Fax:304-624-3918
Practice Address - Street 1:304 MASONIC AVE
Practice Address - Street 2:
Practice Address - City:PENNSBORO
Practice Address - State:WV
Practice Address - Zip Code:26415-1324
Practice Address - Country:US
Practice Address - Phone:304-659-2986
Practice Address - Fax:304-659-2988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51D0710961291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6705061000Medicaid