Provider Demographics
NPI:1821489469
Name:BRAXTON COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BRAXTON COUNTY MEMORIAL HOSPITAL
Other - Org Name:BRAXTON COUNTY MEMORIAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-364-1128
Mailing Address - Street 1:100 HOYLMAN DR
Mailing Address - Street 2:
Mailing Address - City:GASSAWAY
Mailing Address - State:WV
Mailing Address - Zip Code:26624-9318
Mailing Address - Country:US
Mailing Address - Phone:304-364-5156
Mailing Address - Fax:304-364-5809
Practice Address - Street 1:100 HOYLMAN DR
Practice Address - Street 2:
Practice Address - City:GASSAWAY
Practice Address - State:WV
Practice Address - Zip Code:26624-9318
Practice Address - Country:US
Practice Address - Phone:304-364-5156
Practice Address - Fax:304-364-5809
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-17
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4006002000Medicaid
WV5113081Medicare PIN