Basic Information
| Provider Information | |||||||||
| NPI: | 1376533810 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEONATOLOGY CENTER OF WINCHESTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1910 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226048060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668784221 | ||||||||
| FaxNumber: | 5405364359 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 AMHERST ST | ||||||||
| Address2: | SUITE 4C | ||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405367897 | ||||||||
| FaxNumber: | 5405367843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLAWSON | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5405367897 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 400188500 | 05 | MD | MEDICAID | 120591 | 01 | VA | SOUTHERN HEALTH | OTHER | 16566 | 01 | VA | COMMNUITY HEALTH CHN | OTHER | 1881947 | 05 | PA | MEDICAID | 231638 | 01 | VA | ANTHEM BC/BS | OTHER | 006718442 | 05 | VA | MEDICAID | 200507150A | 05 | IN | MEDICAID | 3810005227 | 05 | WV | MEDICAID |