1548660152 NPI number — PHILIP R MASTERSON NP

Table of content: PHILIP R MASTERSON NP (NPI 1548660152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548660152 NPI number — PHILIP R MASTERSON NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASTERSON
Provider First Name:
PHILIP
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1548660152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 CHARTER COLONY PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLOTHIAN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23114-4584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-281-0275
Provider Business Mailing Address Fax Number:
804-521-9344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 CHARTER COLONY PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLOTHIAN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23114-4584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-281-0275
Provider Business Practice Location Address Fax Number:
804-521-9344
Provider Enumeration Date:
09/02/2014

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: 363LF0000X , with the licence number:  0024171888 , 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: C09633 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".