Provider Demographics
NPI:1003058629
Name:PENINSULA REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:PENINSULA REGIONAL MEDICAL CENTER
Other - Org Name:ISLAND FAMILY MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-543-7531
Mailing Address - Street 1:100 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801
Mailing Address - Country:US
Mailing Address - Phone:410-543-7252
Mailing Address - Fax:410-912-6386
Practice Address - Street 1:6295 TEAL LN
Practice Address - Street 2:ISLAND FAMILY MEDICINE
Practice Address - City:CHINCOTEAGUE
Practice Address - State:VA
Practice Address - Zip Code:23336-2207
Practice Address - Country:US
Practice Address - Phone:757-336-2200
Practice Address - Fax:757-336-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10607Medicare PIN