1083647531 NPI number — DR. ELLSWORTH J STAY MD

Table of content: DR. ELLSWORTH J STAY MD (NPI 1083647531)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083647531 NPI number — DR. ELLSWORTH J STAY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAY
Provider First Name:
ELLSWORTH
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1083647531
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22207-0308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-292-1387
Provider Business Mailing Address Fax Number:
502-456-4440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1625 N GEORGE MASON DR
Provider Second Line Business Practice Location Address:
PATHOLOGY DEPT
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22205-3683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-558-6541
Provider Business Practice Location Address Fax Number:
502-456-4440
Provider Enumeration Date:
07/08/2006

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: 207ZP0102X , with the licence number:  0101-029766 , 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: 339836 . This is a "OPTIMUM CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 490050CC62678 . This is a "SECTION 1011 MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 96-2465316 . This is a "WORKERS COMP DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 006601782 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 220017496 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 240523 . This is a "ANTHEM BLUE CROSS BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 339836 . This is a "MDIPA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16699 . This is a "GEORGE WASHINGTON UNIV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 033007700 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1305167 . This is a "UNITED MINE WORKERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 339836 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 506849 . This is a "NATIONAL CAPITAL PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 879500200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1022-0004 . This is a "CAREFIRST BLUE CROSS DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 11-00210 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".




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