Provider Demographics
NPI:1114009941
Name:PRESTON MEMORIAL MEDICAL GROUP
Entity Type:Organization
Organization Name:PRESTON MEMORIAL MEDICAL GROUP
Other - Org Name:GRAFTON CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-329-4700
Mailing Address - Street 1:300 S PRICE ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1442
Mailing Address - Country:US
Mailing Address - Phone:304-329-2830
Mailing Address - Fax:304-791-3737
Practice Address - Street 1:500 MARKET STREET
Practice Address - Street 2:GRAFTON CITY HOSPTIAL
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354
Practice Address - Country:US
Practice Address - Phone:304-265-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0007709000Medicaid
WV001710365OtherHOLEHOUSE, JAMES BCBS
WV9255726Medicare PIN
WV001710365OtherHOLEHOUSE, JAMES BCBS
HO0650014Medicare UPIN