Basic Information
| Provider Information | |||||||||
| NPI: | 1326099219 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TANGLEWOOD FAMILY MEDICINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9782 HWY 903 | ||||||||
| Address2: | |||||||||
| City: | BRACEY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239191991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346366903 | ||||||||
| FaxNumber: | 4346363826 | ||||||||
| Practice Location | |||||||||
| Address1: | 9782 HWY 903 | ||||||||
| Address2: | |||||||||
| City: | BRACEY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239191991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346366903 | ||||||||
| FaxNumber: | 4346363826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 08/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | BAILEY | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | P VP S T | ||||||||
| AuthorizedOfficialTelephone: | 4346366903 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CL0333 | 01 | MEDICARE RAILROAD GROUP NUMBER | OTHER |