1629420005 NPI number — VITAL MEDICAL EQUIPMENT

Table of content: TROY JAY BUSHMAN D.O. (NPI 1194068437)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629420005 NPI number — VITAL MEDICAL EQUIPMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITAL MEDICAL EQUIPMENT
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:
1629420005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11715 FAIRFAX WOODS WAY APT 9103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22030-8345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-782-9327
Provider Business Mailing Address Fax Number:
703-782-9365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6399 LITTLE RIVER TPKE
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22312-5093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-782-9327
Provider Business Practice Location Address Fax Number:
703-782-9365
Provider Enumeration Date:
07/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
VALDEZ
Authorized Official First Name:
KENDRY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
703-782-9327

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1720526 , 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: 1720526 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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