Provider Demographics
NPI:1235596677
Name:TYGART VALLEY MEDICAL SPECIALTIES, INC
Entity Type:Organization
Organization Name:TYGART VALLEY MEDICAL SPECIALTIES, INC
Other - Org Name:MEDCORP-TYGART VALLEY MEDICAL SPECIALTIES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-637-6302
Mailing Address - Street 1:911 GORMAN AVENUE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241
Mailing Address - Country:US
Mailing Address - Phone:304-637-6302
Mailing Address - Fax:304-637-6307
Practice Address - Street 1:911 GORMAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3154
Practice Address - Country:US
Practice Address - Phone:304-637-6302
Practice Address - Fax:304-637-6307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21597261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty