1184686453 NPI number — MRS. PHYLLIS R ROSS OTR/L, CHT, CLT

Table of content: EVAN JAY PA-C (NPI 1366812836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184686453 NPI number — MRS. PHYLLIS R ROSS OTR/L, CHT, CLT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSS
Provider First Name:
PHYLLIS
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L, CHT, CLT
Provider Gender Code:
F

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:
1184686453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 KANAWAH RUN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORKTOWN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23693-2780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-595-4880
Provider Business Mailing Address Fax Number:
757-595-4886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11712 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23606-4406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-595-4880
Provider Business Practice Location Address Fax Number:
757-595-4886
Provider Enumeration Date:
04/04/2006

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: 225X00000X , with the licence number:  0119002028 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X , with the licence number: 0119002028 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XH1300X , with the licence number: 0119002028 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XN1300X , with the licence number: 0119002028 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XP0200X , with the licence number: 0119002028 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 226300000X , with the licence number: 0119002028 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 008948721 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2101706 . This is a "ALLIANCE PPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 462361 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7202455 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2101706 . This is a "MAMSI / GEHA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2062541 . This is a "MAIL HANDLERS BENIFITS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00204753 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 70510 . This is a "VETRI SYSTEMS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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