Tug River Health Association, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Gary, WV
NPI 1174501068 · NPPES record last updated Apr 8, 2022
Key facts
- NPI
- 1174501068
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- License
- 031000 (WV)
- Legal business name
- TUG RIVER HEALTH ASSOCIATION, INC
- Practice address
- US RT 52 Main Street
Gary, WV 24836 - Phone
- (304) 448-2101
- Fax
- (304) 448-3217
- NPI assigned
- Jan 3, 2006
- Organization subpart
- No
Authorized official
- Name
- Mrs. Shari Agnew
- Title
- Credentialing Coordinator
- Phone
- (304) 862-2588
Owners & managing parties with NPI records 5
Owned or controlled facilities with NPI records 1
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 5
Corporate family (same tax ID) 14
Facilities with the same owner 1
Practitioners 31
-
Julia Blevins, FNP-C
-
Andrew Brown, FNP-C
-
Adam S. Hodovan, APRN-BC
-
Jennifer Marie Johnson, FNP-C
-
Tracey L Lester, FNP-BC
-
Amanda Bliss Perry, FNP-BC
-
Robin Elizabeth Riddle, FNP-C
-
Keisha R Saunders, FNP-BC
-
Amy Lee West, FNP-BC
-
Monique Shantae Rash, NP-C
-
Rosalind Rebecca Berry, APRN
-
Sandra L Estep, FNP-BC
-
Kari Beth Law, MD
-
Julie Massey, FNP-C
-
Angela G McKinney, NP-C
-
Katherine Steele, MD
-
Anthony Wayne Thacker, M.D.
-
Matthew Dellacona, D.O.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in WV
Federally qualified health center certification: CCN 511819
- Legal name
- TUG RIVER HEALTH ASSOCIATION, INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Oct 1, 1991
- Last certification
- Oct 1, 1991
- Ownership / control type
- For profit – partnership
- Organization structure
- Corporation · Non-profit
- Incorporated
- Apr 1, 1976 in WV
- Enrollment address
- RR 103
Gary, WV 24836 - Related CCNs
- 513802
Federally qualified health center certification: CCN 581808
- Legal name
- TUG RIVER HEALTH ASSOCIATION, INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Apr 8, 2021
- Last certification
- Apr 8, 2021
- Ownership / control type
- For profit – corporation
- Organization structure
- LLC · Non-profit
- Enrollment address
- 200 12TH Street Ext
Princeton, WV 24740-2329
All disclosed owners & managing parties 11
| Name | Role | Since | Share |
|---|---|---|---|
| Andrea Thornton |
Corporate Director |
Jan 1, 2023 | |
| W-2 Managing Employee | Jan 1, 2023 | ||
| Corporate Director | Jan 1, 2023 | ||
| Lindy Walker |
Corporate Officer | Jun 22, 2014 | |
| David Dunson |
Corporate Director | Nov 1, 2010 | |
| Fred Odum |
Corporate Officer | May 22, 2011 | |
| Micheal Lushbaugh |
Corporate Director | Nov 1, 2010 | |
| Lana Kibbey |
Corporate Director | Nov 1, 2010 | |
| Shari Agnew |
W-2 Managing Employee | Jan 10, 2022 | |
| Clara L Thompson |
Corporate Director | Nov 1, 2010 | |
| John Calloway |
Corporate Director | Nov 1, 2010 | |
| Timothy a Crofton |
Contracted Managing Employee | Jul 1, 2020 | |
| Corporate Director | Jul 1, 2000 | ||
| Operational/Managerial Control | Jan 1, 2000 | ||
| Other | Jan 1, 2000 | ||
| Tug River Health Association, Inc |
5% Or Greater Direct Ownership Interest | Jan 1, 2000 |
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| Tug River Riverview Wellness Center |
Federally qualified health center | Operational/Managerial Control | Mar 1, 2011 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20051010000216 | WV | Part B Supplier - Public Health/Welfare Agency | 7214820547 |
Receives reassigned benefits from 30 practitioners 2 other NPIs on this enrollment Practice locations: Gary, WV; Northfork, WV; Pineville, WV |
| O20101110000234 | WV | Part a Provider - Federally Qualified Health Center (FQHC) | 7214820547 | Practice locations: Gary, WV |
| O20210408001662 | WV | Part a Provider - Federally Qualified Health Center (FQHC) | 7214820547 | Practice locations: Princeton, WV |
National Provider Directory
- Tax ID family
- Tug River Health Association Inc
Locations
1880 Mount View Rd
#500
Welch, WV 24801
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | 031000 | WV | Yes |
Addresses
Primary practice location
US RT 52 Main Street
Gary, WV 24836
Mailing address
Route 103, Supply St.
Pob 507
Gary, WV 24836
Phone (304) 448-2101
Other practice location 1
RR 103 Supply Street
Gary, WV 24836
Phone (304) 448-2101
Other practice location 2
200 12th Street Ext
Princeton, WV 24740-2329
Phone (304) 431-1400
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| CN3563 | Other | WV | RR MEDICARE GROUP # |
| 001706659 | Other | WV | BCBS |
| 0035211000 | Medicaid | WV |
Other providers in Gary, WV
- Jacosta Ann McKinney
- John Roger Ray
- Malinda Grace Royce
- Keisha R Saunders
- Tug River Health Association
- Tug River Health Association, Inc
- Tug River Health Association, Inc
- Tug River Health Association, Inc
- Tug River Health Association, Inc.
- Venus Leasing Co., LLC
All providers in Gary, WV · Federally Qualified Health Center (FQHC) in West Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 8, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.