=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093922726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STONEWALL PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 HOUSTON ST SUITE E
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24450-2455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-463-3162
-----------------------------------------------------
Fax | 540-463-3213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 HOUSTON ST SUITE E
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24450-2455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-463-3162
-----------------------------------------------------
Fax | 540-463-3213
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRICIAN - PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM M JACOBS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 540-463-3162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0101030878
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------