1437504354 NPI number — GARST CLINIC PLC

Table of content: (NPI 1437504354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437504354 NPI number — GARST CLINIC PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARST CLINIC PLC
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:
1437504354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3609 BRANDON AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-1525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-297-3440
Provider Business Mailing Address Fax Number:
540-297-9313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3609 BRANDON AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-1525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-297-3440
Provider Business Practice Location Address Fax Number:
540-297-9313
Provider Enumeration Date:
04/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GARST
Authorized Official First Name:
GARY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
540-297-3440

Provider Taxonomy Codes

  • Taxonomy code: 111NX0800X , with the licence number:  0104000405 , 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: 1437504354 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 460180 . This is a "OPTUM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2089536 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: C09282 . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0004158926 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 142884 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1437504354 . This is a "UNITEDHEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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