1124004296 NPI number — COUNTRYSIDE ORTHOPAEDICS PC

Table of content: (NPI 1124004296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124004296 NPI number — COUNTRYSIDE ORTHOPAEDICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRYSIDE ORTHOPAEDICS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COUNTRYSIDE ORTHOPAEDICPHYSICAL THERAPY AND HAND REHABILITATION CENTER
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124004296
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19465 DEERFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 405
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20176-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-858-1800
Provider Business Mailing Address Fax Number:
703-858-1801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19465 DEERFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE 405
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20176-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-858-1800
Provider Business Practice Location Address Fax Number:
703-858-1801
Provider Enumeration Date:
12/20/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOWER
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-858-1800

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)