Provider Demographics
NPI:1639135221
Name:BOONE MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:BOONE MEMORIAL HOSPITAL, INC
Other - Org Name:BOONE MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-369-1230
Mailing Address - Street 1:701 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1669
Mailing Address - Country:US
Mailing Address - Phone:304-369-1230
Mailing Address - Fax:304-369-6036
Practice Address - Street 1:701 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1669
Practice Address - Country:US
Practice Address - Phone:304-369-1230
Practice Address - Fax:304-369-6036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV119282NC0060X
WVIP05507703336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2109661OtherPK
WV0102256000Medicaid
2109661OtherPK