NPIMap

Organization Active NPI

Tug River Health Association, Inc

  • Federally Qualified Health Center (FQHC)
  • Gary, WV
National Provider Identifier
1174501068
Registry record updated Apr 8, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
031000 Issued in 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
Last updated
Apr 8, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 8, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Shari Agnew
Title
Credentialing Coordinator
Phone
(304) 862-2588

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 031000 WV Primary

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

200 12th Street Ext
Princeton, WV 24740-2329
Phone (304) 431-1400

Other practice location 2

RR 103 Supply Street
Gary, WV 24836
Phone (304) 448-2101

Other identifiers 3

IdentifierTypeStateIssuer
001706659OtherWVBCBS
0035211000MedicaidWV
CN3563OtherWVRR MEDICARE GROUP #

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1174501068. Details of each certification follow.

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
CorporationNon-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
LLCNon-profit
Enrollment address
200 12TH Street Ext
Princeton, WV 24740-2329

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Tug River Clinic15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

Organizations that report the same tax identification number in the National Provider Directory.

View all 14

Locations

200 12th Street Ext
Princeton, WV 24740
Phone (304) 425-1711

1880 Mount View Rd
#500
Welch, WV 24801

1880 Mount View Rd
Ste 500
Welch, WV 24801
Phone (304) 436-4798

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Andrea Thornton Individual Corporate DirectorCeo Jan 1, 2023
W-2 Managing Employee Jan 1, 2023
Corporate Director Jan 1, 2023
Lindy Walker Individual Corporate Officer Jun 22, 2014
David Dunson Individual Corporate Director Nov 1, 2010
Fred Odum Individual Corporate Officer May 22, 2011
Micheal Lushbaugh Individual Corporate Director Nov 1, 2010
Lana Kibbey Individual Corporate Director Nov 1, 2010
Shari Agnew Individual W-2 Managing Employee Jan 10, 2022
Clara L Thompson Individual Corporate Director Nov 1, 2010
John Calloway Individual Corporate Director Nov 1, 2010
Timothy a Crofton Individual 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 Organization, Gary, WV Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2000

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Tug River Riverview Wellness CenterBradshaw, WV, CCN 511973 Federally qualified health center Operational/Managerial Control Mar 1, 2011

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 30

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 30

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1136246400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1649376000000",
    "number": "1174501068",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "ROUTE 103, SUPPLY ST.",
            "address_2": "POB 507",
            "city": "GARY",
            "state": "WV",
            "postal_code": "24836",
            "telephone_number": "304-448-2101",
            "fax_number": "304-448-3217"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "US RT 52 MAIN STREET",
            "city": "GARY",
            "state": "WV",
            "postal_code": "24836",
            "telephone_number": "304-448-2101",
            "fax_number": "304-448-3217"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "200 12th Street Ext",
            "address_purpose": "LOCATION",
            "city": "Princeton",
            "state": "WV",
            "postal_code": "247402329",
            "country_code": "US",
            "telephone_number": "304-431-1400",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "RR 103 Supply Street",
            "address_purpose": "LOCATION",
            "city": "Gary",
            "state": "WV",
            "postal_code": "24836",
            "country_code": "US",
            "telephone_number": "304-448-2101",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "TUG RIVER HEALTH ASSOCIATION, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-01-03",
        "last_updated": "2022-04-08",
        "certification_date": "2022-03-28",
        "status": "A",
        "authorized_official_last_name": "AGNEW",
        "authorized_official_first_name": "SHARI",
        "authorized_official_title_or_position": "CREDENTIALING COORDINATOR",
        "authorized_official_telephone_number": "304-862-2588",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "WV",
            "license": "031000",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "001706659",
            "state": "WV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0035211000",
            "state": "WV"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE GROUP #",
            "identifier": "CN3563",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Gary, WV

Sources for this page

Verify at the official NPI Registry.