1174643878 NPI number — SPOTSYLVANIA EMERGI-CENTER INC

Table of content: (NPI 1174643878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174643878 NPI number — SPOTSYLVANIA EMERGI-CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPOTSYLVANIA EMERGI-CENTER INC
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:
SPOTSYLVANIA EMERGI-CENTER
Provider Other Organization Name Type Code:
5
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:
1174643878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
992 BRAGG RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22407-6979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-786-7637
Provider Business Mailing Address Fax Number:
540-786-0810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
992 BRAGG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22407-6979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-786-7637
Provider Business Practice Location Address Fax Number:
540-786-0810
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEBRON
Authorized Official First Name:
DESIDERIO
Authorized Official Middle Name:
LANDAS
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
540-786-7637

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  0101022289 , 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: 060154 . This is a "ANTHEM BLUE CROSS PPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 060133 . This is a "ANTHEM BLUE CROSS GROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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