1174629448 NPI number — CHARLES FREDERICK LOVELL JR. MD

Table of content: CHARLES FREDERICK LOVELL JR. MD (NPI 1174629448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174629448 NPI number — CHARLES FREDERICK LOVELL JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOVELL
Provider First Name:
CHARLES
Provider Middle Name:
FREDERICK
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1174629448
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
142 W. YORK STREET
Provider Second Line Business Mailing Address:
SUITE 905
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23510-2015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-623-3038
Provider Business Mailing Address Fax Number:
757-623-0101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
142 W. YORK STREET
Provider Second Line Business Practice Location Address:
SUITE 905
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23510-2015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-623-3038
Provider Business Practice Location Address Fax Number:
757-623-0101
Provider Enumeration Date:
09/15/2006

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: 207R00000X , with the licence number:  0101027439 , 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: 006354 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006074936 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111936953 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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