Provider Demographics
NPI:1730309642
Name:BROOKE COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:BROOKE COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPETRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-737-3665
Mailing Address - Street 1:632 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-1743
Mailing Address - Country:US
Mailing Address - Phone:304-737-3665
Mailing Address - Fax:304-737-3689
Practice Address - Street 1:632 MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-1743
Practice Address - Country:US
Practice Address - Phone:304-737-3665
Practice Address - Fax:304-737-3689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17078251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0021216004Medicaid