Basic Information
| Provider Information | |||||||||
| NPI: | 1144218694 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OHIO VALLEY MEDICAL QUICKCARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 417 GRAND PARK DR | ||||||||
| Address2: | STE 103 | ||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261054049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044852700 | ||||||||
| FaxNumber: | 3044850481 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 PIKE ST | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457503323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744540 | ||||||||
| FaxNumber: | 7403743373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 02/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | JURADO | ||||||||
| AuthorizedOfficialFirstName: | JOHNNY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3044852700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2208891 | 05 | OH | MEDICAID | 0019701003 | 05 | WV | MEDICAID |