Healthcare Provider Details

I. General information

NPI: 1508974940
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF WINCHESTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 AMHERST ST BLDG C
WINCHESTER VA
22601-3323
US

IV. Provider business mailing address

1002 AMHERST ST BLDG C
WINCHESTER VA
22601-3323
US

V. Phone/Fax

Practice location:
  • Phone: 540-662-3853
  • Fax: 540-662-0336
Mailing address:
  • Phone: 540-662-3853
  • Fax: 540-662-0336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIDGET DENISE GIBSON
Title or Position: INSURANCE COORDINATOR/ACCTS RECEIVA
Credential:
Phone: 540-662-3853