Provider Demographics
NPI:1669633962
Name:STONEWALL JACKSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:STONEWALL JACKSON MEMORIAL HOSPITAL
Other - Org Name:MOUNTAINEER HEALTHCARE FOR WOMEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-269-8000
Mailing Address - Street 1:230 HOSPITAL PLZ
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-8558
Mailing Address - Country:US
Mailing Address - Phone:304-269-8000
Mailing Address - Fax:304-269-8090
Practice Address - Street 1:66 HOSPITAL PLZ
Practice Address - Street 2:SUITE 103
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-8552
Practice Address - Country:US
Practice Address - Phone:304-269-3108
Practice Address - Fax:304-269-3109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20690207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001417002Medicaid
WV0001417002Medicaid