MEDICARE: JENNIFER K STIRGWOLT DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0102204513	VA

General Provider Information

NPI Number	:	1417117391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER K STIRGWOLT DO

Provider Business Mailing Address
First Line	:	856 J CLYDE MORRIS BLVD STE A
Second Line	:	RIVERSIDE MEDICAL GROUP
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23601-1318
Country	:	US
Telephone Number	:	757-594-4006
Fax Number	:

Provider Business Practice Location Address
First Line	:	4917 RICHMOND TAPPAHANNOCK HWY STE 1B
Second Line	:	KING WILLIAM MEDICAL CENTER
City	:	AYLETT
State	:	VA
Zip	:	23009-3416
Country	:	US
Telephone Number	:	804-769-1245
Fax Number	:	804-769-1342

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2008
Last Update Date	:	11/30/2016

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