Basic Information
| Provider Information | |||||||||
| NPI: | 1962453936 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINCHESTER MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WINCHESTER REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 CAMPUS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405365100 | ||||||||
| FaxNumber: | 5405360235 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 W CORK ST | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226013870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405365114 | ||||||||
| FaxNumber: | 5405365139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AMOS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 5405362607 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINCHESTER MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | H1914 | VA | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 000039 | 01 | VA | ANTHEM | OTHER | 005055500 | 05 | MD | MEDICAID | 2121886 | 01 | VA | OPTIMUM CHOICE, MDIPA | OTHER | 0059412 | 01 | VA | UNITED MINE WORKERS - IP | OTHER | 148653500 | 01 | VA | US DEPARTMENT OF LABOR | OTHER | 092338900 | 05 | FL | MEDICAID | 531913 | 01 | VA | NCPPO | OTHER | 2121886 | 01 | VA | MAMSI, MAPSI, ALLIANCE | OTHER | 0059420 | 01 | VA | UNITED MINE WORKERS - OP | OTHER | 004930339 | 05 | VA | MEDICAID |