NPIMap

Organization Active NPI

Potomac Valley Hospital of W VA , Inc

  • Rural Health Clinic/Center
  • Keyser, WV
National Provider Identifier
1467090449
Registry record updated Dec 20, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
POTOMAC VALLEY HOSPITAL OF W VA , INC
Practice address
100 Pin Oak LN Ste 3
Keyser, WV 26726-5908
Phone
(304) 597-3790
Fax
(304) 597-3564
NPI assigned
Dec 20, 2019
Last updated
Dec 20, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
POTOMAC VALLEY HOSPITAL OF W VA , INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 20, 2019

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

Authorized official

Name
Sue A Wells
Title
Senior Director of Clinic Operation
Phone
(304) 597-3525

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

100 Pin Oak LN Ste 3
Keyser, WV 26726-5908

Mailing address

1370 Johnson Ave Ste 102
Bridgeport, WV 26330-1492
Phone (681) 342-3453

Other names 1

  • Mineral County Rural Health Clinic of Potomac Valley Hospital Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200221001072 WV Part A Provider - Rural Health Clinic 8123917788 Practice locations: Keyser, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1467090449. Details of each certification follow.

Rural health clinic certification: CCN 513426

Legal name
POTOMAC VALLEY HOSPITAL OF W VA , INC
Doing business as
MINERAL COUNTY RURAL HEALTH CLINIC OF POTOMAC VALLEY HOSPITAL
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 12, 2020
Last certification
Aug 12, 2020
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1958 in WV
Enrollment address
100 Pin Oak LN
Ste 3
Keyser, WV 26726-5908
Related CCNs
511315

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 5

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
51D2169085Mineral Co Rural Health Clinic of Potomac100 Pin Oak LN Ste 3, Keyser, WV 26726Certificate of waiverJul 15, 2027

National Provider Directory

National Provider Directory
Tax ID family
Potomac Valley Hospital28 organizations share this tax ID, including this one
Part of
Potomac Valley Hospital

Other organizations with this tax ID 27

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

View all 27

Locations

1370 Johnson Ave
Ste 102
Bridgeport, WV 26330
Phone (681) 342-3452

100 Pin Oak Ln
Ste 3
Keyser, WV 26726
Phone (304) 597-3790

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Jerry E Whisner Individual Corporate Director Sep 1, 2017
Michael Joseph Gould Individual Corporate Director Aug 10, 2021
Marjorie S Fridkin Individual Corporate Director Sep 21, 2023
Kevin Clark Individual Corporate Director Mar 27, 2018
Dinah Courrier Individual Corporate Director Nov 20, 2019
Lewis Kitzmiller Individual Corporate Director Jul 20, 2022
West Virginia United Health System, Inc Organization, Morgantown, WV Non-profit Operational/Managerial Control Jan 1, 2005
Mark Boucot Individual W-2 Managing EmployeeCeo Jan 1, 2018
Harshad S Bokil Individual Corporate Director Sep 21, 2023
Frances L Jones Individual Corporate Director Nov 27, 2018
Sue a Wells Individual W-2 Managing Employee Apr 3, 2014
Robin Haupt Individual Corporate Director Sep 1, 2017

Owners & managing parties with NPI records 3

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

Facilities with the same owner 52

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

View all 52

Practitioners & affiliated clinicians

Practitioners 26

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 26

NPI Registry JSON

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

{
    "created_epoch": "1576800000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1576800000000",
    "number": "1467090449",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1370 JOHNSON AVE STE 102",
            "city": "BRIDGEPORT",
            "state": "WV",
            "postal_code": "263301492",
            "telephone_number": "681-342-3453",
            "fax_number": "304-842-2333"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 PIN OAK LN STE 3",
            "city": "KEYSER",
            "state": "WV",
            "postal_code": "267265908",
            "telephone_number": "304-597-3790",
            "fax_number": "304-597-3564"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "POTOMAC VALLEY HOSPITAL OF W VA , INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "POTOMAC VALLEY HOSPITAL OF W VA , INC",
        "enumeration_date": "2019-12-20",
        "last_updated": "2019-12-20",
        "certification_date": "2019-12-20",
        "status": "A",
        "authorized_official_last_name": "WELLS",
        "authorized_official_first_name": "SUE",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "SENIOR DIRECTOR OF CLINIC OPERATION",
        "authorized_official_telephone_number": "304-597-3525"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mineral County Rural Health Clinic of Potomac Valley Hospital",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Keyser, WV

Sources for this page

Verify at the official NPI Registry.