Provider Demographics
NPI:1417280355
Name:PVH SERFONTEIN OFFICE
Entity Type:Organization
Organization Name:PVH SERFONTEIN OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO, VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:SCHAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-675-4340
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:PT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-0236
Mailing Address - Country:US
Mailing Address - Phone:304-675-1020
Mailing Address - Fax:304-675-5893
Practice Address - Street 1:2418 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:PT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-1528
Practice Address - Country:US
Practice Address - Phone:304-675-6835
Practice Address - Fax:304-675-6849
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLEASANT VALLEY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001774Medicaid
OH2548390Medicaid
WV3810001774Medicaid