Basic Information
| Provider Information | |||||||||
| NPI: | 1477751915 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELKTON FAMILY AND CHILDRENS MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 E ROCKINGHAM ST | ||||||||
| Address2: | |||||||||
| City: | ELKTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 228271522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402989900 | ||||||||
| FaxNumber: | 5402988991 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 E ROCKINGHAM ST | ||||||||
| Address2: | |||||||||
| City: | ELKTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 228271522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402989900 | ||||||||
| FaxNumber: | 5402988991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 12/23/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HILL | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | GRAYSON | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5402989900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | 0024166329 | VA | N | Agencies | Voluntary or Charitable | 261QP2300X | 0024166329 | VA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 010119146 | 05 | VA | MEDICAID | 1134126626 | 01 | VA | INDIVIDUAL NPI NUMBER | OTHER | 1477751915 | 01 | VA | EFCMC NPI | OTHER | 5689660 | 05 | VA | MEDICAID | C10418 | 01 | VA | PTAN | OTHER | 0101031417 | 01 | VA | DR STAUFFER'S VA LICENSE | OTHER | 1538190434 | 01 | VA | DR. STAUFFER NPI | OTHER |