Provider Demographics
NPI:1861698953
Name:REYNOLDS MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:REYNOLDS MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SICURELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-843-3379
Mailing Address - Street 1:800 WHEELING AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1660
Mailing Address - Country:US
Mailing Address - Phone:304-853-3379
Mailing Address - Fax:
Practice Address - Street 1:800 WHEELING AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1660
Practice Address - Country:US
Practice Address - Phone:304-853-3379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REYNOLDS MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-25
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVOP0551193332BP3500X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001309003Medicaid
WVINF045OtherUPPER OHIO VALLEY HP PROV
WV001748043OtherMT. STATE BCBS
WVINF045OtherUPPER OHIO VALLEY HP PROV