Provider Demographics
NPI:1619410693
Name:SUMMERSVILLE OUTPATIENT CENTER
Entity Type:Organization
Organization Name:SUMMERSVILLE OUTPATIENT CENTER
Other - Org Name:SUMMERSVILLE UROLOGY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:REVENUE CYCLE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KINCELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-883-0220
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:304-872-6854
Practice Address - Street 1:702 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-2018
Practice Address - Country:US
Practice Address - Phone:304-883-2380
Practice Address - Fax:304-872-6854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty