1194803338 NPI number — SOUTHSIDE HEAD N NECK SURGERY PROFESSIONAL CORP

Table of content: (NPI 1194803338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194803338 NPI number — SOUTHSIDE HEAD N NECK SURGERY PROFESSIONAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE HEAD N NECK SURGERY PROFESSIONAL CORP
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:
1194803338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 SOUTH AVE.
Provider Second Line Business Mailing Address:
SUITE 4B
Provider Business Mailing Address City Name:
COLONIAL HEIGHTS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-504-0530
Provider Business Mailing Address Fax Number:
804-504-0532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 SOUTH AVE.
Provider Second Line Business Practice Location Address:
SUITE 4B
Provider Business Practice Location Address City Name:
COLONIAL HEIGHTS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-504-0530
Provider Business Practice Location Address Fax Number:
804-504-0532
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANGCUESTA
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
804-337-1110

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  0101036702 , 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: 040009007 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00002082 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006555055 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00002088 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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