1780916122 NPI number — MS. MICHELLE REBECCA SEVERSON D.C.

Table of content: MS. MICHELLE REBECCA SEVERSON D.C. (NPI 1780916122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780916122 NPI number — MS. MICHELLE REBECCA SEVERSON D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEVERSON
Provider First Name:
MICHELLE
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1780916122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
920 TANYARD RD
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
ROCKY MOUNT
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24151-1543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-483-4344
Provider Business Mailing Address Fax Number:
844-726-9867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 TANYARD RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
ROCKY MOUNT
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24151-1543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-483-3678
Provider Business Practice Location Address Fax Number:
540-483-3820
Provider Enumeration Date:
02/10/2010

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: 111N00000X , with the licence number:  0104556868 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: DC010498 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: C05545 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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