1790744423 NPI number — GLOUCESTER ORTHOPAEDIC CLINIC P C

Table of content: (NPI 1790744423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790744423 NPI number — GLOUCESTER ORTHOPAEDIC CLINIC P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLOUCESTER ORTHOPAEDIC CLINIC P C
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:
6
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:
1790744423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 646
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLOUCESTER
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23061-0646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-693-4645
Provider Business Mailing Address Fax Number:
804-693-5985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7584 HOSPITAL DR
Provider Second Line Business Practice Location Address:
BUILDING C, SUITE 202
Provider Business Practice Location Address City Name:
GLOUCESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23061-4178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-693-4645
Provider Business Practice Location Address Fax Number:
804-693-5985
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRAWFORD
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
BACH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
804-693-4645

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  0101042323 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: 0101032226 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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