Provider Demographics
NPI:1841230661
Name:PRESTON MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:PRESTON MEMORIAL HOSPITAL CORPORATION
Other - Org Name:HOSPITAL MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-329-1400
Mailing Address - Street 1:150 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537
Mailing Address - Country:US
Mailing Address - Phone:304-329-1400
Mailing Address - Fax:304-329-1175
Practice Address - Street 1:150 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537
Practice Address - Country:US
Practice Address - Phone:304-329-1400
Practice Address - Fax:304-329-1175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV56207L00000X, 207P00000X, 207Q00000X, 207T00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV97818AMedicaid
WVWV17028AMedicaid
WV001706817OtherBCBS GROUP
WV0104806001Medicaid
WV001808002OtherBCBS ANES GROUP
WVWV97818Medicaid
WV001808002OtherBCBS ANES GROUP
WVWV17028AMedicaid
WV=========002OtherCHAMPUS/TRICARE GROUP
WV5100051Medicare PIN