1215089099 NPI number — DR. GWENDOLYN LEE GEFFERT M.D.

Table of content: (NPI 1568900512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215089099 NPI number — DR. GWENDOLYN LEE GEFFERT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEFFERT
Provider First Name:
GWENDOLYN
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1215089099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5842 ALLIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCE GEORGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23875-2363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-862-4414
Provider Business Mailing Address Fax Number:
804-862-3203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5842 ALLIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCE GEORGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23875-2363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-862-4414
Provider Business Practice Location Address Fax Number:
804-862-3203
Provider Enumeration Date:
01/18/2007

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: 208D00000X , 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: 7609261 . This is a "AETNA PPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 154898 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 111514 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3489701 . This is a "AETNA HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5621097 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 286055 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3489701 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 8122303 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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