Provider Demographics
NPI:1003860602
Name:HAYGOOD PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:HAYGOOD PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MILDREW
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:757-460-3363
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-460-1809
Mailing Address - Fax:
Practice Address - Street 1:1024 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5503
Practice Address - Country:US
Practice Address - Phone:757-460-1809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA081242OtherANTHEM
VA=========OtherTRICARE