1619016375 NPI number — SALTERS CREEK MEDICAL GROUP

Table of content: (NPI 1619016375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619016375 NPI number — SALTERS CREEK MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALTERS CREEK MEDICAL GROUP
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:
1619016375
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 BRIDGE STREET
Provider Second Line Business Mailing Address:
#D
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-723-1899
Provider Business Mailing Address Fax Number:
757-723-5425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
183 WOODLAND ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-723-1899
Provider Business Practice Location Address Fax Number:
757-723-5425
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STEELE
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
757-812-9809

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  0104001272 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207Q00000X , with the licence number: 0101053117 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: BCBS330020 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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