1437504354 NPI number — GARST CLINIC PLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437504354 NPI number — GARST CLINIC PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARST CLINIC PLC
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:
Provider Other Organization Name Type Code:
6
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:
1437504354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3609 BRANDON AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-1525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-297-3440
Provider Business Mailing Address Fax Number:
540-297-9313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3609 BRANDON AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-1525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-297-3440
Provider Business Practice Location Address Fax Number:
540-297-9313
Provider Enumeration Date:
04/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GARST
Authorized Official First Name:
GARY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
540-297-3440

Provider Taxonomy Codes

  • Taxonomy code: 111NX0800X , with the licence number:  0104000405 , 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: 1437504354 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 460180 . This is a "OPTUM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2089536 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: C09282 . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0004158926 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 142884 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1437504354 . This is a "UNITEDHEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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