Provider Demographics
NPI:1619969706
Name:STATE OF WEST VIRGINIA
Entity Type:Organization
Organization Name:STATE OF WEST VIRGINIA
Other - Org Name:JACKIE WITHROW HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:PARENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-256-6600
Mailing Address - Street 1:105 S EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4929
Mailing Address - Country:US
Mailing Address - Phone:304-256-6600
Mailing Address - Fax:304-250-6554
Practice Address - Street 1:105 S EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4929
Practice Address - Country:US
Practice Address - Phone:304-256-6600
Practice Address - Fax:304-250-6554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV181313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0003978000Medicaid