1124072293 NPI number — VALLEY UROLOGY PC

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 1124072293 NPI number — VALLEY UROLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY UROLOGY 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:
6
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:
1124072293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
136 LINDEN DR
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22601-2818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-678-3588
Provider Business Mailing Address Fax Number:
540-678-9025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1104 AMHERST ST
Provider Second Line Business Practice Location Address:
STE. 204
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22601-3340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-678-3867
Provider Business Practice Location Address Fax Number:
540-678-1440
Provider Enumeration Date:
05/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHESSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
540-678-3867

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1124072293 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810010693 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7574420001 . This is a "MEDICARE DME" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: DF3147 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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