Healthcare Provider Details

I. General information

NPI: 1104158401
Provider Name (Legal Business Name): FORT CHISWELL FAMILY CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 FORT CHISWELL RD SUITE A
MAX MEADOWS VA
24360-4139
US

IV. Provider business mailing address

791 FORT CHISWELL RD SUITE A
MAX MEADOWS VA
24360-4139
US

V. Phone/Fax

Practice location:
  • Phone: 276-637-6641
  • Fax: 276-637-6741
Mailing address:
  • Phone: 276-637-6641
  • Fax: 276-637-6741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL H STOKER
Title or Position: PHYSICIAN
Credential: MD
Phone: 276-637-6641