1750358750 NPI number — DR. KIRBY D SOUTHALL M.D.

Table of content: DR. KIRBY D SOUTHALL M.D. (NPI 1750358750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750358750 NPI number — DR. KIRBY D SOUTHALL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHALL
Provider First Name:
KIRBY
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1750358750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5609 CLAIBORNE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUTHERLAND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23885-9303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-265-5211
Provider Business Mailing Address Fax Number:
804-265-2707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5609 CLAIBORNE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUTHERLAND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23885-9303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-265-5211
Provider Business Practice Location Address Fax Number:
804-265-2707
Provider Enumeration Date:
03/08/2006

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: 207Q00000X , with the licence number:  0101039352 , 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: 828665 . This is a "OPT CHOICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 100629 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5697727 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080642 . This is a "QUALCHOICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 45882 . This is a "SENTARA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 815042 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5697727 . This is a "VA. PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 577244 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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