Basic Information
Provider Information | |||||||||
NPI: | 1962586461 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPIVEY | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1031 CARE WAY | ||||||||
Address2: |   | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224018425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403717600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1031 CARE WAY | ||||||||
Address2: |   | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224018425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403717600 | ||||||||
FaxNumber: | 5403712046 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 12/02/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 0101018720 | VA | N |   | Other Service Providers | Legal Medicine |   | 174400000X | 0101018720 | VA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 10806 | 01 | VA | SENTARA | OTHER | 0002 | 01 | VA | CAREFIRST | OTHER | 169553 | 01 | VA | ANTHEM BCBS | OTHER | 201718482 | 01 | VA | VMA S/HEALTH CARENET | OTHER | 201718482011 | 01 | VA | CHAMPUS/TRICARE | OTHER | 4091856 | 01 | VA | AETNA | OTHER | 250916 | 01 | VA | SOUTHERN HEALTH | OTHER | 100006740 | 01 | VA | RAILROAD MEDICARE | OTHER | 3730259 | 01 | VA | AENTA HMO | OTHER | 477493 | 01 | VA | MAMSI | OTHER | 010272017 | 05 | VA |   | MEDICAID | 477493 | 01 | VA | UNITED HEALTHCARE | OTHER |