Provider Demographics
NPI:1710389093
Name:ST. JOSEPH'S HOSPITAL OF BUCKHANNON, INC.
Entity Type:Organization
Organization Name:ST. JOSEPH'S HOSPITAL OF BUCKHANNON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAR
Authorized Official - Middle Name:H
Authorized Official - Last Name:GJOLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:304-473-2118
Mailing Address - Street 1:1 AMALIA DR
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2239
Mailing Address - Country:US
Mailing Address - Phone:304-473-2000
Mailing Address - Fax:
Practice Address - Street 1:129 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1706
Practice Address - Country:US
Practice Address - Phone:304-473-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOSEPH'S HOSPITAL OF BUCKHANNON, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-18
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015677Medicaid