Provider Demographics
NPI:1548246622
Name:BROADDUS HOSPITAL ASSOCIATION, INC.
Entity type:Organization
Organization Name:BROADDUS HOSPITAL ASSOCIATION, INC.
Other - Org Name:
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:304-457-8155
Mailing Address - Street 1:#1 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:304-457-1760
Mailing Address - Fax:304-457-1516
Practice Address - Street 1:#1 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:304-457-1760
Practice Address - Fax:304-457-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV96282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0002167000Medicaid
WVCE1018OtherMEDICARE RAILROAD
WV0002167000Medicaid