Provider Demographics
NPI:1255507810
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:COMMUNITY CARE PEDIATRICS OF BUCKHANNON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-545-0571
Mailing Address - Street 1:4 NORTHRIDGE DR STE 118
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-8484
Mailing Address - Country:US
Mailing Address - Phone:304-473-5660
Mailing Address - Fax:304-473-5661
Practice Address - Street 1:4 NORTHRIDGE DR STE 118
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-8484
Practice Address - Country:US
Practice Address - Phone:304-473-5660
Practice Address - Fax:304-473-5661
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-05
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1255507810Medicaid
WV3810013076Medicaid
WV511938Medicare Oscar/Certification