1740227909 NPI number — FOOT AND ANKLE CLINIC OF THE VIRGINIAS INC

Table of content: (NPI 1740227909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740227909 NPI number — FOOT AND ANKLE CLINIC OF THE VIRGINIAS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT AND ANKLE CLINIC OF THE VIRGINIAS INC
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:
1740227909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 365
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROSPERITY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25909-0365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-292-3008
Provider Business Mailing Address Fax Number:
866-420-4578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 ROGERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24740-3636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-292-3008
Provider Business Practice Location Address Fax Number:
412-291-1552
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DONATELLI
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
800-292-3008

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010201641 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD3197 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001706519 . This is a "MOUNTAIN STATE BC BS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810007768 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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