Basic Information
| Provider Information | |||||||||
| NPI: | 1053814129 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINCHESTER MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VALLEY HEALTH PULMONARY SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7402 | ||||||||
| Address2: | |||||||||
| City: | MERRIFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221167402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006552656 | ||||||||
| FaxNumber: | 4128227411 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 CAMPUS BLVD STE 410 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405365980 | ||||||||
| FaxNumber: | 4128227411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2018 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | FAHRENHOLD | ||||||||
| AuthorizedOfficialFirstName: | KELLI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8006552656 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINCHESTER MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.