Provider Demographics
NPI:1780767772
Name:UNITED HOSPITAL CENTER
Entity type:Organization
Organization Name:UNITED HOSPITAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:681-342-1000
Mailing Address - Street 1:527 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:681-342-3500
Mailing Address - Fax:681-342-3507
Practice Address - Street 1:710 GENESIS BLVD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9668
Practice Address - Country:US
Practice Address - Phone:681-342-3490
Practice Address - Fax:681-342-3491
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNITED HOSPITAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV107207R00000X
207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001709473OtherBLUE CROSS PAY TO NUMBER
WV3810008622Medicaid
WV001709473OtherBLUE CROSS PAY TO NUMBER