1386802015 NPI number — MICHAEL L GWALTNEY MD

Table of content: MICHAEL L GWALTNEY MD (NPI 1386802015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386802015 NPI number — MICHAEL L GWALTNEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GWALTNEY
Provider First Name:
MICHAEL
Provider Middle Name:
L
Provider Name Prefix Text:
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:
1386802015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 388
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FISHERSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22939-0388
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-932-5162
Provider Business Mailing Address Fax Number:
540-932-5875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
78 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FISHERSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22939-2332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-932-4075
Provider Business Practice Location Address Fax Number:
540-932-5199
Provider Enumeration Date:
05/29/2008

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: 208000000X , with the licence number:  0101249737 , 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)