Provider Demographics
NPI:1275728628
Name:POTOMAC HIGHLANDS GUILD
Entity Type:Organization
Organization Name:POTOMAC HIGHLANDS GUILD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-257-1155
Mailing Address - Street 1:6 PARK ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1765
Mailing Address - Country:US
Mailing Address - Phone:304-257-1155
Mailing Address - Fax:304-257-1945
Practice Address - Street 1:6 PARK ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1765
Practice Address - Country:US
Practice Address - Phone:304-257-1155
Practice Address - Fax:304-257-1945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14000251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005473002Medicaid