1376530816 NPI number — DR. FRAZIER T FORTENBERRY JR. MD

Table of content: DR. FRAZIER T FORTENBERRY JR. MD (NPI 1376530816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376530816 NPI number — DR. FRAZIER T FORTENBERRY JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTENBERRY
Provider First Name:
FRAZIER
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1376530816
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 PETER JEFFERSON PKWY
Provider Second Line Business Mailing Address:
SUITE 135
Provider Business Mailing Address City Name:
CHARLOTTESVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22911-8605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-244-5722
Provider Business Mailing Address Fax Number:
434-244-5723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 PETER JEFFERSON PKWY
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
CHARLOTTESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22911-8605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-244-5722
Provider Business Practice Location Address Fax Number:
434-244-5723
Provider Enumeration Date:
09/30/2005

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: 208800000X , with the licence number:  0101044989 , 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: 14120 . This is a "COMMUNITY HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 23555 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 461522 . This is a "ANTHEM SERVICES" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00003207 . This is a "MEDICARE PIN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 367104 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 204175 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 340000300 . This is a "MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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