Basic Information
Provider Information | |||||||||
NPI: | 1790979136 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREEN SPRING PATIENT FIRST SERIES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PATIENT FIRST BAYVIEW | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5000 COX RD | ||||||||
Address2: | SUITE 100 PATIENT FIRST | ||||||||
City: | GLEN ALLEN | ||||||||
State: | VA | ||||||||
PostalCode: | 23060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8048224383 | ||||||||
FaxNumber: | 8049650987 | ||||||||
Practice Location | |||||||||
Address1: | 5100 EASTERN AVENUE | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 21224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108144500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2007 | ||||||||
LastUpdateDate: | 08/29/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRIDGERS | ||||||||
AuthorizedOfficialFirstName: | MARVIN | ||||||||
AuthorizedOfficialMiddleName: | WARREN | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY SERVICES | ||||||||
AuthorizedOfficialTelephone: | 8048224383 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GREEN SPRING PATIENT FIRST SERIES | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: | RPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X |   |   | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
No ID Information.