Provider Demographics
NPI:1497853600
Name:ST. GEORGE MEDICAL CLINIC INC.
Entity Type:Organization
Organization Name:ST. GEORGE MEDICAL CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAMSLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:304-478-3339
Mailing Address - Street 1:8591 HOLLY MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:WV
Mailing Address - Zip Code:26287-8604
Mailing Address - Country:US
Mailing Address - Phone:304-478-3339
Mailing Address - Fax:304-478-3311
Practice Address - Street 1:8591 HOLLY MEADOWS RD
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:WV
Practice Address - Zip Code:26287-8604
Practice Address - Country:US
Practice Address - Phone:304-478-3339
Practice Address - Fax:304-478-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0035139000Medicaid
WV0035139000Medicaid
WVST9169481Medicare PIN