1104826429 NPI number — DR. WALTER W IMMEL M.D.

Table of content: DR. WALTER W IMMEL M.D. (NPI 1104826429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104826429 NPI number — DR. WALTER W IMMEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IMMEL
Provider First Name:
WALTER
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1104826429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5510 ALMA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22151-4012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-642-5990
Provider Business Mailing Address Fax Number:
703-642-5003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5510 ALMA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22151-4012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-642-5990
Provider Business Practice Location Address Fax Number:
703-642-5003
Provider Enumeration Date:
07/28/2005

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: 207RG0100X , with the licence number:  0101039106 , 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: 4091831 . This is a "AHP MGD CHOICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 723556 . This is a "AFFORDABLE FIRST HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 51166 . This is a "MDIPA/OPTIMUM CHOICE/MAMS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2900048 . This is a "UNITED HEALTH VIRGINIA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2006963 . This is a "AETNA/US HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 224009 . This is a "HEALTHKEEPERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2900633 . This is a "UNITED HEALTH MID-ATLANTI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5819393 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45560002 . This is a "BCBS DC CAPCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1965376002 . This is a "CIGNA HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 224009 . This is a "TRIGON KEYAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 505112 . This is a "NCPPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 630385 . This is a "ONE HEALTH GREATWEST" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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