Provider Demographics
NPI:1720183197
Name:ST. JOSEPH'S HOSPITAL OF BUCKHANNON, INC.
Entity Type:Organization
Organization Name:ST. JOSEPH'S HOSPITAL OF BUCKHANNON, INC.
Other - Org Name:ST. JOSEPH'S HOSPITAL NURSING CARE FACILITY
Other - Org Type:Other Name
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:JR
Authorized Official - Credentials:
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:26201-2276
Mailing Address - Country:US
Mailing Address - Phone:304-473-2000
Mailing Address - Fax:304-473-2180
Practice Address - Street 1:1 AMALIA DR
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2276
Practice Address - Country:US
Practice Address - Phone:304-473-2000
Practice Address - Fax:304-473-2180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV87314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001139003Medicaid
WV515051Medicare ID - Type UnspecifiedMEDICARE