Provider Demographics
NPI:1083617989
Name:STONEWALL JACKSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:STONEWALL JACKSON MEMORIAL HOSPITAL
Other - Org Name:STONEWALL JACKSON HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF EXTERNAL OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:M.
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:EISENBEIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:304-269-4556
Mailing Address - Street 1:456 SUITE B MARKET PLACE MALL
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-6938
Mailing Address - Country:US
Mailing Address - Phone:304-269-4556
Mailing Address - Fax:304-269-4559
Practice Address - Street 1:456 SUITE B MARKET PLACE MALL
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-6938
Practice Address - Country:US
Practice Address - Phone:304-269-4556
Practice Address - Fax:304-269-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV300699OtherFEDERAL BLACK LUNG
WVWV22958AOtherHEALTH PLAN
WV0001417001Medicaid
WV=========002OtherCHAMPUS/PALMETTO
WVWV22958AOtherHEALTH PLAN
WV300699OtherFEDERAL BLACK LUNG
WV=========018OtherACORDIA NAT'L, HLTH ASSUR
WV=========06OtherWORKERS COMPENSATION
WV517104Medicare Oscar/Certification