1801013115 NPI number — AMBULATORY FOOT CARE CENTER P C

Table of content: (NPI 1801013115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801013115 NPI number — AMBULATORY FOOT CARE CENTER P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMBULATORY FOOT CARE CENTER 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:
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:
1801013115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
789 PINEY FOREST RD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24540-2877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-799-9430
Provider Business Mailing Address Fax Number:
434-792-8438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
789 PINEY FOREST RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24540-2877
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-799-9430
Provider Business Practice Location Address Fax Number:
434-792-8438
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CANAVAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
434-799-9430

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  0103 000583 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1891739991 . This is a "DR MICHAEL CANAVAN NPI #" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 009301631 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46126 . This is a "OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 890803N , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891739991 . This is a "MUTUAL OF OMAHA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: C02497 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: CF9579 . This is a "RET RAILROAD MCRE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 066476 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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