1922171149 NPI number — CYNTHIA POORTENGA, MD PC

Table of content: (NPI 1922171149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922171149 NPI number — CYNTHIA POORTENGA, MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CYNTHIA POORTENGA, MD PC
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:
CYNTHIA POORTENGA, MD PC
Provider Other Organization Name Type Code:
3
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:
1922171149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 E RAVINE RD
Provider Second Line Business Mailing Address:
STE 900
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-3816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-230-4800
Provider Business Mailing Address Fax Number:
423-230-4808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 E RAVINE RD
Provider Second Line Business Practice Location Address:
STE 900
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-230-4800
Provider Business Practice Location Address Fax Number:
423-230-4808
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POORTENGA
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
423-230-4800

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MD0000017131 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3372564 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5645956 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 246269 . This is a "ANTHEM BCBS VA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4054392 . This is a "BCBS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com