1912226358 NPI number — FAVERO FAMILY PRACTICE INCORPORATED

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912226358 NPI number — FAVERO FAMILY PRACTICE INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAVERO FAMILY PRACTICE INCORPORATED
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:
MARTINSVILLE FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
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:
1912226358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5544
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTINSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24115-5544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-666-0500
Provider Business Mailing Address Fax Number:
276-666-0400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
445 COMMONWEALTH BLVD E
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MARTINSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24112-2086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-666-0500
Provider Business Practice Location Address Fax Number:
276-666-0400
Provider Enumeration Date:
05/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FAVERO
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
276-666-0500

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0102202434 , 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)





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