Provider Demographics
NPI:1629241880
Name:WILLOW RIDGE PLLC
Entity Type:Organization
Organization Name:WILLOW RIDGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:HAMM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-645-7503
Mailing Address - Street 1:333 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-1116
Mailing Address - Country:US
Mailing Address - Phone:304-645-7503
Mailing Address - Fax:304-645-7582
Practice Address - Street 1:333 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1116
Practice Address - Country:US
Practice Address - Phone:304-645-7503
Practice Address - Fax:304-645-7582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001633Medicaid
WV3810001633Medicaid