Basic Information
| Provider Information | |||||||||
| NPI: | 1174564389 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNINGTON GAP HMA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LEE REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | WEST MORGAN AVENUE | ||||||||
| Address2: | |||||||||
| City: | PENNINGTON GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765461440 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | WEST MORGAN AVENUE | ||||||||
| Address2: | |||||||||
| City: | PENNINGTON GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765461440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARRY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP AND GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 2395983176 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ESQ | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | Y | Hospital Units | Medicare Defined Swing Bed Unit |
No ID Information.