1912928011 NPI number — PAUL D CHIDESTER MD ET AL

Table of content: (NPI 1912928011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912928011 NPI number — PAUL D CHIDESTER MD ET AL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL D CHIDESTER MD ET AL
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:
1912928011
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:
PO BOX 7068
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23707-0068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-686-3508
Provider Business Mailing Address Fax Number:
757-686-0541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-4985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-410-8791
Provider Business Practice Location Address Fax Number:
757-410-8783
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHIDESTER
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
757-436-6959

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 194475 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7660794 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 319574 . This is a "MDIPA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 15097 . This is a "SENTARA OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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