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Marietta Memorial Hospital of Tyler County Inc

Organization Active NPI Rural Health Clinic/Center · Middlebourne, WV

NPI 1508465162 · NPPES record last updated May 7, 2021

Key facts

NPI
1508465162
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
MARIETTA MEMORIAL HOSPITAL OF TYLER COUNTY INC
Practice address
100 Fair St
Middlebourne, WV 26149-9525
Phone
(304) 758-5000
Fax
(304) 758-5022
NPI assigned
Oct 23, 2020
Organization subpart
No

Authorized official

Name
Paul Westbrock
Title
VP, Legal Affairs
Phone
(740) 374-1581

Owners & managing parties with NPI records 3

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

Owned or controlled facilities with NPI records 1

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

Other NPIs on the same Medicare enrollment 7

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

Other NPIs with the same Medicare PAC ID 6

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

Corporate family (same tax ID) 5

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

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

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in WV

Rural health clinic certification: CCN 513413

Legal name
MARIETTA MEMORIAL HOSPITAL OF TYLER COUNTY INC
Doing business as
SISTERSVILLE GENERAL MEDICAL CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 7, 2010
Last certification
Aug 16, 2023
Ownership / control type
2B
Most recent change of ownership
Oct 1, 2020 (1 total)
Organization structure
Corporation · Non-profit
Incorporated
Oct 1, 2020 in WV
Enrollment address
100 Fair St
Middlebourne, WV 26149-9525
Related CCNs
511304

All disclosed owners & managing parties 19

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

NameRoleSinceShare
Charlotte Hatfield
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
James Barengo
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Sheryl Holdren
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Terry E Rataiczak
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Michael Iaderosa
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Joseph D Cooper
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Rebekah Gilden
Individual 		W-2 Managing Employee
Compliance & Privacy Coordinator		 Oct 1, 2020
Matthew J Macatol
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Paul G Westbrock
Individual 		W-2 Managing Employee
Compliance Officer		 Oct 1, 2020
Larry Unroe
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Colleen Cook
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Thomas Danford
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Thomas Tucker
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Scott Silvestri
Individual 		W-2 Managing Employee
Cfo		 Oct 1, 2020
Michael Archer
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Gregg M Emerick
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
Jeffrey Scott Cantley
Individual 		W-2 Managing Employee
Ceo		 Oct 1, 2020
Stephen C Keiser
Individual 		Corporate Director
Board of Director		 Oct 1, 2020
John Lee
Individual 		Corporate Director
Board of Director		 Oct 1, 2020

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Sistersville General Hospital Swing Bed Unit
Sistersville, WV · CCN 51Z304		 Hospital 5% Or Greater Direct Ownership Interest (100%) Oct 1, 2020

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20201210003158 WV Part a Provider - Rural Health Clinic 4385055342 Practice locations: Middlebourne, WV
O20210601001753 WV Part B Supplier - Clinic/Group Practice 4385055342 Receives reassigned benefits from 45 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Middlebourne, WV; Saint Marys, WV; Sistersville, WV; Williamstown, WV

National Provider Directory

Tax ID family
Marietta Memorial Hospital of Tyler County Inc (6 organizations share this tax ID)

Specialties & licenses

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

Addresses

Primary practice location

100 Fair St
Middlebourne, WV 26149-9525

Mailing address

C/O Paul Westbrock
314 S Wells St
Sistersville, WV 26175
Phone (304) 652-2611

Other names

  • Sistersville General Medical Center Doing business as

Other providers in Middlebourne, WV

All providers in Middlebourne, WV · Rural Health Clinic/Center in West Virginia

Sources for this page

Verify at the official NPI Registry.