Provider Demographics
| NPI: | 1275558017 |
|---|---|
| Name: | CENTRAL WV MEDCORP, INC. |
| Entity Type: | Organization |
| Organization Name: | CENTRAL WV MEDCORP, INC. |
| Other - Org Name: | BUCKHANNON MEDICAL CARE |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | CFO |
| Authorized Official - Prefix: | MS |
| Authorized Official - First Name: | REBECCA |
| Authorized Official - Middle Name: | JEAN |
| Authorized Official - Last Name: | HAMMER |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 304-637-3156 |
| Mailing Address - Street 1: | PO BOX 2630 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | ELKINS |
| Mailing Address - State: | WV |
| Mailing Address - Zip Code: | 26241-2630 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 304-637-3736 |
| Mailing Address - Fax: | 304-637-3369 |
| Practice Address - Street 1: | 11 N LOCUST ST |
| Practice Address - Street 2: | |
| Practice Address - City: | BUCKHANNON |
| Practice Address - State: | WV |
| Practice Address - Zip Code: | 26201-2231 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 304-472-1600 |
| Practice Address - Fax: | 304-472-6382 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-07-13 |
| Last Update Date: | 2011-10-31 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101YP2500X, 207RG0300X, 208000000X | ||
| WV | 207P00000X, 207Q00000X, 207R00000X, 207Y00000X, 208600000X, 2086S0129X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| WV | 3810010990 | Medicaid | |
| WV | 000897320 | Other | MT ST BCBS GROUP NUMBER |
| WV | 151585801 | Other | DOL FEDERAL BLACK LUNG PR |
| WV | 001710531 | Other | MT ST BCBS PAC PAY TO # |
| WV | 020935300 | Other | DOL FEDERAL BLACK LUNG PR |
| WV | 0009078000 | Medicaid | |
| WV | 020935302 | Other | DOL FEDERAL BLACK LUNG PR |
| WV | 020935300 | Other | DOL FEDERAL BLACK LUNG PR |
| WV | 020935300 | Other | DOL FEDERAL BLACK LUNG PR |
| WV | CE9277346 | Medicare PIN | |
| WV | CE9356173 | Medicare PIN | |
| WV | 51-3916 | Medicare PIN | |
| WV | CE9277345 | Medicare PIN | |
| WV | 151585801 | Other | DOL FEDERAL BLACK LUNG PR |
| WV | 001710531 | Other | MT ST BCBS PAC PAY TO # |
| WV | 3810010990 | Medicaid | |
| WV | CE9277341 | Medicare PIN | |
| WV | CE9277349 | Medicare PIN | |
| WV | CE9277347 | Medicare PIN | |
| WV | CE9277343 | Medicare PIN |
