1679584569 NPI number — MICHAEL ALAN EISENFELD PAC

Table of content: MICHAEL ALAN EISENFELD PAC (NPI 1679584569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679584569 NPI number — MICHAEL ALAN EISENFELD PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EISENFELD
Provider First Name:
MICHAEL
Provider Middle Name:
ALAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1679584569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 CAMPUS BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22601-2896
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-662-0306
Provider Business Mailing Address Fax Number:
855-264-2066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1880 AMHERST STREET
Provider Second Line Business Practice Location Address:
SUITE 100 AND SUITE 200
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-662-0306
Provider Business Practice Location Address Fax Number:
855-264-2066
Provider Enumeration Date:
08/10/2006

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: 363AM0700X , with the licence number:  01340 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 0110-840765 , 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: 970008085 . This is a "RAIL ROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com