Provider Demographics
NPI:1790745677
Name:HOSPITAL DEVELOPMENT CO
Entity Type:Organization
Organization Name:HOSPITAL DEVELOPMENT CO
Other - Org Name:SOUTHERN ROANE MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-927-6200
Mailing Address - Street 1:200 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1050
Mailing Address - Country:US
Mailing Address - Phone:304-927-6819
Mailing Address - Fax:304-927-6837
Practice Address - Street 1:1 LIBRARY LN
Practice Address - Street 2:
Practice Address - City:LEFT HAND
Practice Address - State:WV
Practice Address - Zip Code:25251-9745
Practice Address - Country:US
Practice Address - Phone:304-927-6819
Practice Address - Fax:304-927-6837
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROANE GENERAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-24
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV74261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004237Medicaid
WVHO5113061Medicare ID - Type UnspecifiedPART B GRP ID #
WV3810004237Medicaid