Provider Demographics
NPI:1962540773
Name:WILLIAMSON MEMORIAL HOSPITAL LLC
Entity type:Organization
Organization Name:WILLIAMSON MEMORIAL HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-899-6118
Mailing Address - Street 1:PO BOX 1958
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-1958
Mailing Address - Country:US
Mailing Address - Phone:304-899-6118
Mailing Address - Fax:304-235-0538
Practice Address - Street 1:859 ALDERSON ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3215
Practice Address - Country:US
Practice Address - Phone:304-235-0466
Practice Address - Fax:304-235-0536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001235002Medicaid