NPIMap

Organization Active NPI

Marietta Memorial Hospital of Tyler County Inc

Doing business as Sistersville General Medical Center

  • Rural Health Clinic/Center
  • Middlebourne, WV
National Provider Identifier
1508465162
Registry record updated May 7, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MARIETTA MEMORIAL HOSPITAL OF TYLER COUNTY INC
Doing business as
Sistersville General Medical Center
Practice address
100 Fair St
Middlebourne, WV 26149-9525
Phone
(304) 758-5000
Fax
(304) 758-5022
NPI assigned
Oct 23, 2020
Last updated
May 7, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 7, 2021

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

Authorized official

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

Specialties & licenses 1

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

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 1

  • Sistersville General Medical Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV2 enrollments

Enrollment records 2

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1508465162. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Oct 1, 2020 in WV
Enrollment address
100 Fair St
Middlebourne, WV 26149-9525
Related CCNs
511304

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

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 7

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

National Provider Directory

National Provider Directory
Tax ID family
Marietta Memorial Hospital of Tyler County Inc6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Locations

1861 N Pleasants Hwy
#101
Saint Marys, WV 26170
Phone (681) 612-1022

Ownership & related parties

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

Owners & managing parties with NPI records 3

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

Owned or controlled facilities with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 3

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.

NPI Registry JSON

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

{
    "created_epoch": "1603411200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1620345600000",
    "number": "1508465162",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "C/O PAUL WESTBROCK",
            "address_2": "314 S WELLS ST",
            "city": "SISTERSVILLE",
            "state": "WV",
            "postal_code": "26175",
            "telephone_number": "304-652-2611",
            "fax_number": "304-652-1448"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 FAIR ST",
            "city": "MIDDLEBOURNE",
            "state": "WV",
            "postal_code": "261499525",
            "telephone_number": "304-758-5000",
            "fax_number": "304-758-5022"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARIETTA MEMORIAL HOSPITAL OF TYLER COUNTY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-10-23",
        "last_updated": "2021-05-07",
        "certification_date": "2021-05-07",
        "status": "A",
        "authorized_official_last_name": "WESTBROCK",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "VP, LEGAL AFFAIRS",
        "authorized_official_telephone_number": "740-374-1581"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sistersville General Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Middlebourne, WV

Sources for this page

Verify at the official NPI Registry.