Basic Information
| Provider Information | |||||||||
| NPI: | 1225135072 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NAVAL MEDICAL CENTER PORTSMOUTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PORTS VA BHC OCEANA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | ATTN MRS, GOODRICH 3RD PARTY COLLECTION | ||||||||
| Address2: | 620 JOHN PAUL JONES CIR | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102218274 | ||||||||
| FaxNumber: | 2102218131 | ||||||||
| Practice Location | |||||||||
| Address1: | 1550 TOMCAT BLVD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234602188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147153 | ||||||||
| FaxNumber: | 7573147111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 11/14/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONDON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BUMED UBO | ||||||||
| AuthorizedOfficialTelephone: | 2404013643 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NAVAL MEDICAL CENTER PORTSMOUTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2104685 | 01 | PK | OTHER |