Provider Demographics
NPI:1275528614
Name:WILLIAMSON MEMORIAL HOSPITAL LLC
Entity Type:Organization
Organization Name:WILLIAMSON MEMORIAL HOSPITAL LLC
Other - Org Name:WILLIAMSON MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-235-2500
Mailing Address - Street 1:859 ALDERSON ST
Mailing Address - Street 2:PO BOX 1980
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3215
Mailing Address - Country:US
Mailing Address - Phone:304-235-2500
Mailing Address - Fax:304-235-4549
Practice Address - Street 1:859 ALDERSON ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3215
Practice Address - Country:US
Practice Address - Phone:304-235-2500
Practice Address - Fax:304-235-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207RC0000X, 363LF0000X
WV68282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01690015Medicaid
KY65939423Medicaid
WV0001235000Medicaid
KY65942377Medicaid
CK7099OtherRAILROAD MC
OH0019974Medicaid
DA1751OtherRAILROAD MC
DA7625OtherRAILRAOD MC
CG2287OtherRAILROAD MC
KY6578Medicare PIN
DA1751OtherRAILROAD MC
CG2287OtherRAILROAD MC
WV0001235000Medicaid