1679525810 NPI number — WOODSTOCK SURGICAL CLINIC, PLC

Table of content: (NPI 1679525810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679525810 NPI number — WOODSTOCK SURGICAL CLINIC, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODSTOCK SURGICAL 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:
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:
1679525810
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:
103 W SOUTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22664-1238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-459-3753
Provider Business Mailing Address Fax Number:
540-459-8928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 W SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22664-1238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-459-3753
Provider Business Practice Location Address Fax Number:
540-459-8928
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WYMER
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
HODSON
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
540-459-3753

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00010042747 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 76159338 . This is a "WAUSAU GROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 435027 . This is a "ANTHEM, GROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 435028 . This is a "ANTHEM, DR. CARMAIN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 266315 . This is a "ANTHEM, DR. PULIZZI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 8563807002 . This is a "DR. CARMAIN, CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2188487002 . This is a "DR. PULIZZ CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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