1396876975 NPI number — EASTERN SHORE RURAL HEALTH SYSTEM INCORPORATED

Table of content: (NPI 1396876975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396876975 NPI number — EASTERN SHORE RURAL HEALTH SYSTEM INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN SHORE RURAL HEALTH SYSTEM INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EASTVILLE COMMUNITY HEALTH CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396876975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20280 MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONANCOCK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23417-1331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-414-0400
Provider Business Mailing Address Fax Number:
757-414-0569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17068 LANKFORD HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASTVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23347-0098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-331-1086
Provider Business Practice Location Address Fax Number:
757-442-9505
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
JEANNETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
757-414-0400

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 007600194 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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