1437344041 NPI number — SPINE & INJURY CENTER OF FREDERICKSBURG PC

Table of content: (NPI 1437344041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437344041 NPI number — SPINE & INJURY CENTER OF FREDERICKSBURG PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE & INJURY CENTER OF FREDERICKSBURG PC
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:
1437344041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 PLANK RD
Provider Second Line Business Mailing Address:
SUITE 1022
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22407-0120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-785-0200
Provider Business Mailing Address Fax Number:
540-785-0660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 PLANK RD
Provider Second Line Business Practice Location Address:
SUITE 1022
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22407-0120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-785-0200
Provider Business Practice Location Address Fax Number:
540-785-0660
Provider Enumeration Date:
09/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RENO
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
LEWIS
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
540-785-0200

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  0104555960 , 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: 2101714 . This is a "ALLIANCE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2740701 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 434855 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 50576 . This is a "NVPPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: S974-0001 . This is a "CAREFIRST" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2101714 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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