1568674133 NPI number — DERMATOLOGY CONSULTANTS OF GLOUCESTER P L L C

Table of content: (NPI 1568674133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568674133 NPI number — DERMATOLOGY CONSULTANTS OF GLOUCESTER P L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY CONSULTANTS OF GLOUCESTER P L L C
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:
1568674133
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 693
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLOUCESTER
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-693-6527
Provider Business Mailing Address Fax Number:
804-693-6615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6790 WOOD RIDGE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLOUCESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-693-6527
Provider Business Practice Location Address Fax Number:
804-693-6615
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MUFFELMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
804-693-6527

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  0101026776 , 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: 141598 . This is a "ANTHEM BCBS GROUP NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: CJ9476 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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