Provider Demographics
NPI:1356426944
Name:JUSTICE MEDICAL COMPLEX
Entity type:Organization
Organization Name:JUSTICE MEDICAL COMPLEX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-393-4004
Mailing Address - Street 1:PO BOX 837
Mailing Address - Street 2:
Mailing Address - City:KERMIT
Mailing Address - State:WV
Mailing Address - Zip Code:25674-0837
Mailing Address - Country:US
Mailing Address - Phone:304-393-4004
Mailing Address - Fax:304-393-4167
Practice Address - Street 1:RR BOX 330 US HWY 52
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:WV
Practice Address - Zip Code:25669
Practice Address - Country:US
Practice Address - Phone:304-393-4004
Practice Address - Fax:304-393-4167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65944621Medicaid
WV3810004168Medicaid
WVJU9356861Medicare ID - Type Unspecified