1508887597 NPI number — JANICE M GOMOKE PT

Table of content: JANICE M GOMOKE PT (NPI 1508887597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508887597 NPI number — JANICE M GOMOKE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMOKE
Provider First Name:
JANICE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1508887597
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 69030
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21264-9030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-873-2302
Provider Business Mailing Address Fax Number:
757-873-2306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4020 RAINTREE RD STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23321-3749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-484-4241
Provider Business Practice Location Address Fax Number:
757-484-4487
Provider Enumeration Date:
07/22/2006

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: 225100000X , with the licence number:  2305002436 , 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: 1508887597 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010208793 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00233936 . This is a "MEDICARE RR" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 192941 . This is a "BCBS (PHYSICAL THERAPY)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7899071 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00871013 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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