Provider Demographics
NPI:1144800673
Name:MARIETTA MEMORIAL HOSPITAL OF TYLER COUNTY INC
Entity Type:Organization
Organization Name:MARIETTA MEMORIAL HOSPITAL OF TYLER COUNTY INC
Other - Org Name:PROFESSIONAL SERVICES GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:VP, LEGAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WESTBROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-374-1581
Mailing Address - Street 1:C/O PAUL WESTBROCK
Mailing Address - Street 2:314 S WELLS ST
Mailing Address - City:SISTERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26175
Mailing Address - Country:US
Mailing Address - Phone:740-374-1581
Mailing Address - Fax:
Practice Address - Street 1:314 S WELLS ST
Practice Address - Street 2:
Practice Address - City:SISTERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26175-1098
Practice Address - Country:US
Practice Address - Phone:304-652-2611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty