1972689883 NPI number — DR. ALBERT JOSEPH MUNGO MD

Table of content: DR. ALBERT JOSEPH MUNGO MD (NPI 1972689883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972689883 NPI number — DR. ALBERT JOSEPH MUNGO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNGO
Provider First Name:
ALBERT
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1972689883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 340
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HALIFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-575-1683
Provider Business Mailing Address Fax Number:
434-575-1682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2204 WILBORN AVENUE
Provider Second Line Business Practice Location Address:
HALIFAX REGIONAL HOSPITAL
Provider Business Practice Location Address City Name:
HALIFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-517-3187
Provider Business Practice Location Address Fax Number:
434-517-3686
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  0101235169 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002596 . This is a "BC" identifier . This identifiers is of the category "OTHER".




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