1811063142 NPI number — DR. BEVERLY ANNE GOUGH O.D.

Table of content: DR. BEVERLY ANNE GOUGH O.D. (NPI 1811063142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811063142 NPI number — DR. BEVERLY ANNE GOUGH O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOUGH
Provider First Name:
BEVERLY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1811063142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 OLD GALLOWS RD
Provider Second Line Business Mailing Address:
SUITE 520
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-3990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:
703-991-0514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 OLD GALLOWS RD
Provider Second Line Business Practice Location Address:
SUITE 520
Provider Business Practice Location Address City Name:
VIENNA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22182-3990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-847-8899
Provider Business Practice Location Address Fax Number:
703-991-0514
Provider Enumeration Date:
11/28/2006

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: 152W00000X , with the licence number:  S-680 TA-388 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 1351 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09311 . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DE7256 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 00343 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 8909311 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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