Basic Information
Provider Information | |||||||||
NPI: | 1235164641 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GITTINGS | ||||||||
FirstName: | MICHELE | ||||||||
MiddleName: | SUZAN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KOVALCIK | ||||||||
OtherFirstName: | MICHELE | ||||||||
OtherMiddleName: | SUZAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA C | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 13700 | ||||||||
Address2: | COMMONWEALTH EMERGENCY PHYSICIANS PC | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191910001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8007772455 | ||||||||
FaxNumber: | 6106176280 | ||||||||
Practice Location | |||||||||
Address1: | 44045 RIVERSIDE PKWY | ||||||||
Address2: | LOUDOUN HOSPITAL CENTER | ||||||||
City: | LEESBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 201765101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038586044 | ||||||||
FaxNumber: | 6106176280 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 11/21/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110 001865 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.