Provider Demographics
NPI:1215097613
Name:BROADDUS HOSPITAL ASSOCIATION, INC.
Entity type:Organization
Organization Name:BROADDUS HOSPITAL ASSOCIATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-457-1760
Mailing Address - Street 1:#5 HEALTHCARE DRIVE
Mailing Address - Street 2:P.O. BOX 930
Mailing Address - City:PHILIPPI
Mailing Address - State:WV
Mailing Address - Zip Code:26416
Mailing Address - Country:US
Mailing Address - Phone:304-457-8535
Mailing Address - Fax:304-457-1516
Practice Address - Street 1:#5 HEALTHCARE DRIVE
Practice Address - Street 2:MANSFIELD HILL
Practice Address - City:PHILIPPI
Practice Address - State:WV
Practice Address - Zip Code:26416
Practice Address - Country:US
Practice Address - Phone:304-457-8535
Practice Address - Fax:304-457-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV96314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0002167001Medicaid
WV51-5129Medicare ID - Type Unspecified