Provider Demographics
NPI:1396949616
Name:WEIRTON MEDICAL CENTER INC
Entity type:Organization
Organization Name:WEIRTON MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:STAFF
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-723-4328
Mailing Address - Street 1:PO BOX 2581
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-1781
Mailing Address - Country:US
Mailing Address - Phone:304-723-6040
Mailing Address - Fax:
Practice Address - Street 1:651 COLLIERS WAY
Practice Address - Street 2:SUITE 502
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5053
Practice Address - Country:US
Practice Address - Phone:304-723-4328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEIRTON MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-12
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19983207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2147582Medicaid
OH9298808Medicaid
WV6000332000Medicaid
WV0001352005Medicaid
WV6000332000Medicaid
OH9298808Medicaid
WV9322343Medicare PIN
G97809Medicare UPIN
WV4088822Medicare PIN