Individual Professional Information |
|
NPI
|
1841376720
|
|
Unique healthcare provider (clinician) ID assigned by NPPES
|
|
PECOS UID
|
3173694056
|
|
Unique individual clinician ID assigned by PECOS
|
|
Professional Enrollment ID
|
I20080620000064
|
|
Unique ID for the individual professional enrollment that is the source for the data in the observation
|
|
Provider Last Name
|
MARSTON
|
|
Individual professional last name
|
|
Provider First Name
|
JONATHAN
|
|
Individual professional first name
|
|
Provider Middle Name
|
ERIC
|
|
Individual professional middle name
|
|
Provider Gender
|
M
|
|
The provider's gender if the provider is a person.
|
Practice Information |
|
Organization Legal Name
|
CREWE MEDICAL CENTER INC
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
6901977883
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
2
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
12522 W COLONIAL TRAIL HWY
|
|
Group Practice or individual's line 1 address
|
|
City
|
CREWE
|
|
Group Practice or individual's city
|
|
State
|
VA
|
|
Group Practice or individual's state
|
|
Zip Code
|
239303329
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
4346459191
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
490090
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
CENTRA SOUTHSIDE COMMUNITY HOSPITAL, INC
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
490112
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
CJW MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Hospital Affiliation CCN 3
|
490021
|
|
Medicare CCN of hospital where individual professional provides service 3
|
|
Hospital Affiliation LBN 3
|
CENTRA
|
|
Legal business name of hospital where individual professional provides service 3
|
|
Hospital Affiliation CCN 4
|
490032
|
|
Medicare CCN of hospital where individual professional provides service 4
|
|
Hospital Affiliation LBN 4
|
MEDICAL COLLEGE OF VIRGINIA HOSPITALS
|
|
Legal business name of hospital where individual professional provides service 4
|
|
Hospital Affiliation CCN 5
|
490059
|
|
Medicare CCN of hospital where individual professional provides service 5
|
|
Hospital Affiliation LBN 5
|
BON SECOURS ST MARYS HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 5
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|