Provider Demographics
NPI:1891176137
Name:ST GEORGE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:ST GEORGE MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:H
Authorized Official - Last Name:WAMSLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:304-478-3339
Mailing Address - Street 1:6420 HOLLY MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:WV
Mailing Address - Zip Code:26287-8055
Mailing Address - Country:US
Mailing Address - Phone:304-478-3339
Mailing Address - Fax:304-478-3311
Practice Address - Street 1:81 TUCKER VALLEY SCHOOL RD
Practice Address - Street 2:
Practice Address - City:HAMBLETON
Practice Address - State:WV
Practice Address - Zip Code:26269-8052
Practice Address - Country:US
Practice Address - Phone:304-478-3339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherUNKNOW