Provider Demographics
NPI:1760733984
Name:WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC
Entity Type:Organization
Organization Name:WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC
Other - Org Name:PARKERSBURG FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING/CREDENTIALING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:KNICELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-275-3301
Mailing Address - Street 1:2610 CAMDEN AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5652
Mailing Address - Country:US
Mailing Address - Phone:304-917-3733
Mailing Address - Fax:304-917-3750
Practice Address - Street 1:2610 CAMDEN AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5652
Practice Address - Country:US
Practice Address - Phone:304-917-3733
Practice Address - Fax:304-917-3750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-27
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0009486002Medicaid
WV0009486002Medicaid
511026Medicare PIN
WVD284Medicare PIN