1639365273 NPI number — MR. GREGORY S DEACON CP

Table of content: MR. GREGORY S DEACON CP (NPI 1639365273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639365273 NPI number — MR. GREGORY S DEACON CP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEACON
Provider First Name:
GREGORY
Provider Middle Name:
S
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CP
Provider Gender Code:
M

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:
1639365273
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4338 WILLIAMSON RD NW
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:
24012-2821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-366-8287
Provider Business Mailing Address Fax Number:
540-366-3050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
MARTINSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24112-1945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-634-5690
Provider Business Practice Location Address Fax Number:
276-634-5691
Provider Enumeration Date:
09/18/2007

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: 224P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7795211 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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