1295879328 NPI number — ARCHWAY 60 FAMILY PRACTICE

Table of content: (NPI 1295879328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295879328 NPI number — ARCHWAY 60 FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARCHWAY 60 FAMILY PRACTICE
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:
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:
1295879328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLOTHIAN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-378-5010
Provider Business Mailing Address Fax Number:
804-378-3264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 HUGUENDT ROAD
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
MIDLOTHIAN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-378-9657
Provider Business Practice Location Address Fax Number:
804-378-7858
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REID
Authorized Official First Name:
DORIS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
804-378-9657

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0056331Z5 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33361Z . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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