Basic Information
| Provider Information | |||||||||
| NPI: | 1740389865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NAVAL MEDICAL CENTER PORTSMOUTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | NAVAL MEDICAL CENTER THIRD PARTY COLLECTIONS | ||||||||
| Address2: | ATTN MRS. GOODRICH 3RD PARTY COLLECTION | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102218274 | ||||||||
| FaxNumber: | 2102218131 | ||||||||
| Practice Location | |||||||||
| Address1: | 1185 TERRIER AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147225 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 11/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | CONDON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BUMED UBO | ||||||||
| AuthorizedOfficialTelephone: | 2404013643 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NAVAL MEDICAL CENTER PORTSMOUTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2104686 | 01 | PK | OTHER |