NPI |
1295481125 |
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
Entity Type Code |
1 |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider Last Name Legal Name |
PHILLIPS |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider First Name |
SAMANTHA |
The city name in the location address of the provider being identified. |
Provider First Line Business Practice Location Address |
1614 S KANAWHA ST |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address City Name |
BECKLEY |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address State Name |
WV |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Postal Code |
258016239 |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider Business Practice Location Address Telephone Number |
3042551397 |
The date that a record was last updated or changed. |
Provider Enumeration Date |
3/1/2022 |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Last Update Date |
3/1/2022 |
The first name of the authorized official. |
Provider Gender Code |
F |
The title or position of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
376J00000X |
The 10-position telephone number of the authorized official. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Other Provider Identifier 1 |
1083825038 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 1 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 1 |
WV |
|
Other Provider Identifier 2 |
1619185147 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 2 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 2 |
WV |
|
Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
NPI Certification Date |
3/1/2022 |
|