1073833760 NPI number — PORTSMOUTH COMMUNITY HEALTH CENTER, INC

Table of content: (NPI 1073833760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073833760 NPI number — PORTSMOUTH COMMUNITY HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTSMOUTH COMMUNITY HEALTH CENTER, 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:
PARK PLACE MEDICAL CENTER
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:
1073833760
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1541 HIGH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23704-3209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-393-6363
Provider Business Mailing Address Fax Number:
757-622-6384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 KINGSLEY LN STE 320
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23505-4629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-533-9108
Provider Business Practice Location Address Fax Number:
757-622-6384
Provider Enumeration Date:
06/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
757-397-0042

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)





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