Provider Demographics
NPI: | 1922155217 |
---|---|
Name: | ST. MARY'S MEDICAL MANAGEMENT, LLC |
Entity Type: | Organization |
Organization Name: | ST. MARY'S MEDICAL MANAGEMENT, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | TODD |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | CAMPBELL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 304-526-8914 |
Mailing Address - Street 1: | PO BOX 4190 |
Mailing Address - Street 2: | |
Mailing Address - City: | BARBOURSVILLE |
Mailing Address - State: | WV |
Mailing Address - Zip Code: | 25504-4190 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 304-908-9201 |
Mailing Address - Fax: | 304-935-3334 |
Practice Address - Street 1: | 2900 1ST AVE |
Practice Address - Street 2: | |
Practice Address - City: | HUNTINGTON |
Practice Address - State: | WV |
Practice Address - Zip Code: | 25702 |
Practice Address - Country: | US |
Practice Address - Phone: | 304-526-1234 |
Practice Address - Fax: | 304-526-1489 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-01-05 |
Last Update Date: | 2018-05-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WV | 001934200 | Other | BSMT MOUNTAIN STATE |
KY | 7100101210 | Medicaid | |
KY | 7100073660 | Medicaid | |
WV | 002016965 | Other | BSMT/ MID LEVEL |
WV | 3810009673 | Other | UNISYS / ST MARY'S LAB |
WV | 3810007944 | Medicaid | |
WV | DH1153 | Medicare PIN | |
WV | 002016965 | Other | BSMT/ MID LEVEL |