Healthcare Provider Details

I. General information

NPI: 1124373808
Provider Name (Legal Business Name): IPS OF WINCHESTER LLC/AFP LOCATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 AMHERST ST
WINCHESTER VA
22601-2801
US

IV. Provider business mailing address

148 LINDEN DR SUITE 101
WINCHESTER VA
22601-6902
US

V. Phone/Fax

Practice location:
  • Phone: 540-667-8724
  • Fax: 540-723-0741
Mailing address:
  • Phone: 540-504-0075
  • Fax: 540-678-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: HARRY NELSON GUSTIN III
Title or Position: MANAGER
Credential: MD
Phone: 540-667-8724