1508055591 NPI number — IRVING S GOTTFRIED MD PC

Table of content: (NPI 1508055591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508055591 NPI number — IRVING S GOTTFRIED MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IRVING S GOTTFRIED MD PC
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:
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:
1508055591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 OAK ST
Provider Second Line Business Mailing Address:
SUITE 2-105
Provider Business Mailing Address City Name:
FARMVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23901-1199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-392-6877
Provider Business Mailing Address Fax Number:
434-392-8809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 OAK ST
Provider Second Line Business Practice Location Address:
SUITE 2-105
Provider Business Practice Location Address City Name:
FARMVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23901-1199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-392-6877
Provider Business Practice Location Address Fax Number:
434-392-8809
Provider Enumeration Date:
10/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOTTFRIED
Authorized Official First Name:
IRVING
Authorized Official Middle Name:
SASS
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
434-392-6877

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  0101039536 , 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: 6046258 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042514 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1000013150 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 53907 . This is a "SENTARA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com