Basic Information
| Provider Information | |||||||||
| NPI: | 1528570884 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CTMC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5943 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234710943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3467045400 | ||||||||
| FaxNumber: | 4135400159 | ||||||||
| Practice Location | |||||||||
| Address1: | 10850 LOUETTA RD STE 1500 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770703537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813202338 | ||||||||
| FaxNumber: | 2813202349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | GILL | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2813202338 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.