Provider Demographics
NPI:1588039242
Name:SUMMERSVILLE OUTPATIENT CENTER
Entity Type:Organization
Organization Name:SUMMERSVILLE OUTPATIENT CENTER
Other - Org Name:ANSTED CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-872-2891
Mailing Address - Street 1:400 FAIRVIEW HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-9308
Mailing Address - Country:US
Mailing Address - Phone:304-883-0220
Mailing Address - Fax:304-872-8417
Practice Address - Street 1:100 FLORENCE STREET
Practice Address - Street 2:
Practice Address - City:ANSTED
Practice Address - State:WV
Practice Address - Zip Code:25812
Practice Address - Country:US
Practice Address - Phone:304-883-0220
Practice Address - Fax:304-872-8417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVSU9208641Medicare Oscar/Certification