Provider Demographics
NPI:1639278518
Name:BRAXTON COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BRAXTON COUNTY MEMORIAL HOSPITAL
Other - Org Name:BRAXTON COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-364-1128
Mailing Address - Street 1:100 HOYLMAN DR
Mailing Address - Street 2:
Mailing Address - City:GASSAWAY
Mailing Address - State:WV
Mailing Address - Zip Code:26624-9321
Mailing Address - Country:US
Mailing Address - Phone:304-364-1093
Mailing Address - Fax:
Practice Address - Street 1:617 RIVER ST
Practice Address - Street 2:
Practice Address - City:GASSAWAY
Practice Address - State:WV
Practice Address - Zip Code:26624-1137
Practice Address - Country:US
Practice Address - Phone:304-364-2401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002207Q00000X
WV031428261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5360015000Medicaid
WVBR5113081OtherMEDICARE PART B GROUP #
WV513400Medicare PIN