Healthcare Provider Details

I. General information

NPI: 1184861973
Provider Name (Legal Business Name): OLDE TOWNE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 NORTH ST
PORTSMOUTH VA
23704-2415
US

IV. Provider business mailing address

640 NORTH ST
PORTSMOUTH VA
23704-2415
US

V. Phone/Fax

Practice location:
  • Phone: 757-397-1246
  • Fax: 757-397-0089
Mailing address:
  • Phone: 757-397-1246
  • Fax: 757-397-0089

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: PATRICIA BUTLER
Title or Position: BILLING MANAGER
Credential:
Phone: 757-638-0085