1780079558 NPI number — MEDICAL AVENUE INTERNAL MEDICINE PC

Table of content: (NPI 1780079558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780079558 NPI number — MEDICAL AVENUE INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL AVENUE INTERNAL MEDICINE PC
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:
1780079558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1920 MEDICAL AVE
Provider Second Line Business Mailing Address:
STE F
Provider Business Mailing Address City Name:
HARRISONBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22801-8016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-908-3095
Provider Business Mailing Address Fax Number:
540-908-3085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1920 MEDICAL AVE
Provider Second Line Business Practice Location Address:
STE F
Provider Business Practice Location Address City Name:
HARRISONBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22801-8016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-908-3095
Provider Business Practice Location Address Fax Number:
540-908-3085
Provider Enumeration Date:
03/30/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAKARIC
Authorized Official First Name:
ILIJA
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
DIRECTOR / INCORPORATOR
Authorized Official Telephone Number:
540-908-3095

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  0101054605 , 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: 1184734154 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21467 . This is a "OPTIMA HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 006023169 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 211236 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".