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General NPI Number Information
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NPI Number | 1487886537
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Entity Type | Organization
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Legal Business Name | MEDSOURCE, LLC
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Dates
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Enumeration Date | 08/21/2009
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Last Update Date | 08/21/2009
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Provider Practice Location Address
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Address Line | 3909 MIDLANDS ROAD, SUITE: B
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City | WILLIAMSBURG
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State | VA
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Zip | 23188
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Country | US
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Telephone | 757-220-5051
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Fax | 757-220-5053
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Provider Business Mailing Address
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Address Line | 3909 MIDLANDS ROAD, SUITE: B
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City | WILLIAMSBURG
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State | VA
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Zip | 23188
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Country | US
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Telephone | 757-220-5051
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Fax | 757-220-5053
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Authorized Official
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Title or Position | PARTNER
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Name | MR. RAY JOSEPH GAGNE
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Credential | EET
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Telephone | 757-220-5051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0101051020
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License Number State | VA
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