Basic Information
Provider Information | |||||||||
NPI: | 1043336639 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPRINGFIELD MEDICAL CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6365 ROLLING MILL PL | ||||||||
Address2: | SUITE 103 | ||||||||
City: | SPRINGFIELD | ||||||||
State: | VA | ||||||||
PostalCode: | 221522353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7035697420 | ||||||||
FaxNumber: | 3019349321 | ||||||||
Practice Location | |||||||||
Address1: | 6365 ROLLING MILL PL | ||||||||
Address2: | SUITE 103 | ||||||||
City: | SPRINGFIELD | ||||||||
State: | VA | ||||||||
PostalCode: | 221522353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7035697420 | ||||||||
FaxNumber: | 3019349321 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FERRER | ||||||||
AuthorizedOfficialFirstName: | ROSARIO | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7035697420 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101038129 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.