Healthcare Provider Details

I. General information

NPI: 1518990100
Provider Name (Legal Business Name): PRIMEDOC OF PORTSMOUTH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 HIGH ST
PORTSMOUTH VA
23707-3236
US

IV. Provider business mailing address

PO BOX 601824
CHARLOTTE NC
28260-1824
US

V. Phone/Fax

Practice location:
  • Phone: 843-237-3378
  • Fax: 843-237-5073
Mailing address:
  • Phone: 843-237-3378
  • Fax: 843-237-5073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberN/A
License Number StateVA

VIII. Authorized Official

Name: ROBERT J REYNOLDS
Title or Position: PRESIDENT
Credential: MD
Phone: 828-210-3260