Provider Demographics
NPI:1124842786
Name:POTOMAC VALLEY HOSPITAL OF W VA , INC
Entity type:Organization
Organization Name:POTOMAC VALLEY HOSPITAL OF W VA , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOUCOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-597-3510
Mailing Address - Street 1:100 PIN OAK LN
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-5908
Mailing Address - Country:US
Mailing Address - Phone:304-597-3510
Mailing Address - Fax:
Practice Address - Street 1:537 S MINERAL ST
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2936
Practice Address - Country:US
Practice Address - Phone:304-788-1274
Practice Address - Fax:304-788-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty