=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538757877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY MIDDLETON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2021
-----------------------------------------------------
Last Update Date | 01/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 656 BURR OAK CT
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678-6118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-387-7051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10645B ROCKFISH GAP TPKE
-----------------------------------------------------
City | AFTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22920-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-280-9003
-----------------------------------------------------
Fax | 800-396-6701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1744R1102X
-----------------------------------------------------
Taxonomy Name | Research Study Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------