1063717304 NPI number — FARMVILLE INTERNAL MEDICINE, PC

Table of content: (NPI 1063717304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063717304 NPI number — FARMVILLE INTERNAL MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FARMVILLE 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:
1063717304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX R
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23901-0289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-392-9000
Provider Business Mailing Address Fax Number:
434-392-9215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 MILNWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23901-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-392-9000
Provider Business Practice Location Address Fax Number:
434-392-9215
Provider Enumeration Date:
01/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BONAGIRI
Authorized Official First Name:
VARA
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
434-392-9000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  0101054184 , 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: 5865514 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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