Basic Information
| Provider Information | |||||||||
| NPI: | 1003058629 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENINSULA REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ISLAND FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105437252 | ||||||||
| FaxNumber: | 4109126386 | ||||||||
| Practice Location | |||||||||
| Address1: | 6295 TEAL LN | ||||||||
| Address2: | ISLAND FAMILY MEDICINE | ||||||||
| City: | CHINCOTEAGUE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233362207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573362200 | ||||||||
| FaxNumber: | 7573362211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2009 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | HORNER | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4105437531 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.