1578511010 NPI number — MERIDIAN MEDICAL GROUP-RETAIL CLINIC PC

Table of content: (NPI 1578511010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578511010 NPI number — MERIDIAN MEDICAL GROUP-RETAIL CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERIDIAN MEDICAL GROUP-RETAIL CLINIC 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:
1578511010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19597
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-580-9491
Provider Business Mailing Address Fax Number:
713-358-4868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 ROUTE 66 FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEPTUNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07753-2605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-807-0800
Provider Business Practice Location Address Fax Number:
732-922-0805
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLARKE
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
732-765-6317

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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