Provider Demographics
NPI:1326037011
Name:BJSM MED INC
Entity Type:Organization
Organization Name:BJSM MED INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-647-6080
Mailing Address - Street 1:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:25213-0808
Mailing Address - Country:US
Mailing Address - Phone:304-586-0771
Mailing Address - Fax:304-586-0799
Practice Address - Street 1:202 MAPLEWOOD AVE
Practice Address - Street 2:GREENBRIER VALLEY MEDICAL CENTER
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1334
Practice Address - Country:US
Practice Address - Phone:304-647-4411
Practice Address - Fax:304-647-6064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4000458000Medicaid
WV4000458000Medicaid