Provider Demographics
NPI:1043397110
Name:GRANT COUNTY BOARD OF HEALTH
Entity type:Organization
Organization Name:GRANT COUNTY BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LOCAL HEALTH OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-257-4922
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:739 NORTH FORK HIGHWAY
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-0608
Mailing Address - Country:US
Mailing Address - Phone:304-257-4922
Mailing Address - Fax:304-257-2422
Practice Address - Street 1:739 NORTH FORK HIGHWAY
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847
Practice Address - Country:US
Practice Address - Phone:304-257-4922
Practice Address - Fax:304-257-2422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0091234000Medicaid
WV0021284000Medicaid
WV9289711Medicare PIN
WV0021284000Medicaid