1417067216 NPI number — GERARD P CHAMPALOUX MD

Table of content: (NPI 1417067216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417067216 NPI number — GERARD P CHAMPALOUX MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERARD P CHAMPALOUX MD
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:
1417067216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14300 GALLANT FOX LANE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
BOWIE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20715-4031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-262-6797
Provider Business Mailing Address Fax Number:
301-262-2564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14300 GALLANT FOX LANE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
BOWIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20715-4031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-262-6797
Provider Business Practice Location Address Fax Number:
301-262-2564
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMPALOUX
Authorized Official First Name:
GERARD
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
301-262-6296

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: 784741600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com