Provider Demographics
NPI:1326186586
Name:WETZEL COUNTY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:WETZEL COUNTY HOSPITAL ASSOCIATION
Other - Org Name:PINE GROVE RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FELICI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-455-8000
Mailing Address - Street 1:P.O. BOX 244
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-2705
Mailing Address - Country:US
Mailing Address - Phone:304-455-8000
Mailing Address - Fax:304-455-4259
Practice Address - Street 1:12960 SHORTLINE HWY
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:WV
Practice Address - Zip Code:26419
Practice Address - Country:US
Practice Address - Phone:304-889-3344
Practice Address - Fax:304-889-3366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
WV261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001221008Medicaid
WV513989Medicare ID - Type UnspecifiedRHC
513989Medicare PIN
WV0001221008Medicaid