Basic Information
| Provider Information | |||||||||
| NPI: | 1588693725 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMEDOC OF NORFOLK PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601835 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432373378 | ||||||||
| FaxNumber: | 8432375073 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 KINGSLEY LN | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235054602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432373378 | ||||||||
| FaxNumber: | 8432375073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | REYNOLDS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8282103260 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1588693725 | 05 | VA | MEDICAID | 246875 | 01 | VA | BLUE SHIELD | OTHER | DF0829 | 01 | VA | RAILROAD MEDICARE | OTHER |