1114920253 NPI number — ERVIN ANTHONY MD

Table of content: ERVIN ANTHONY MD (NPI 1114920253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114920253 NPI number — ERVIN ANTHONY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTHONY
Provider First Name:
ERVIN
Provider Middle Name:
Provider Name Prefix Text:
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:
1114920253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 866
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATHEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23109-0866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-725-9191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10980 BUCKLEY HALL ROAD
Provider Second Line Business Practice Location Address:
BUILDING #5
Provider Business Practice Location Address City Name:
MATHEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23109-2310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-725-9191
Provider Business Practice Location Address Fax Number:
804-725-9120
Provider Enumeration Date:
05/23/2005

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: 207P00000X , with the licence number:  ME53345 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 0101034362 , 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: 049567100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1114920253 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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