Provider Demographics
NPI:1174725188
Name:MONROE COUNTY HEALTH CENTER, BOARD OF TRUSTEES
Entity type:Organization
Organization Name:MONROE COUNTY HEALTH CENTER, BOARD OF TRUSTEES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-772-3064
Mailing Address - Street 1:200 HEALTH CENTER DRIVE
Mailing Address - Street 2:PO BOX 590
Mailing Address - City:UNION
Mailing Address - State:WV
Mailing Address - Zip Code:24983
Mailing Address - Country:US
Mailing Address - Phone:304-772-3064
Mailing Address - Fax:304-772-3296
Practice Address - Street 1:2869 SENECA TRAIL
Practice Address - Street 2:
Practice Address - City:PETERSTOWN
Practice Address - State:WV
Practice Address - Zip Code:24963
Practice Address - Country:US
Practice Address - Phone:304-753-4336
Practice Address - Fax:304-753-4097
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONROE COUNTY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-01
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001706775OtherBC/BS
WV3810011420Medicaid
WV5611053OtherAETNA
WVDB2513OtherMEDICARE RR GROUP
WV5611053OtherAETNA
WVDB2513OtherMEDICARE RR GROUP