1538292123 NPI number — PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC

Table of content: (NPI 1538292123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538292123 NPI number — PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC
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:
MAIN STREET PHYSICIANS
Provider Other Organization Name Type Code:
3
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:
1538292123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1033 28TH ST
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23607-4233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-591-0643
Provider Business Mailing Address Fax Number:
757-591-0682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
157 NORTH MAIN STREET SUITE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-925-1866
Provider Business Practice Location Address Fax Number:
757-928-0906
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FUTRELL
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
757-925-1866

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7687648 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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