Provider Demographics
NPI:1043585623
Name:JACQUELINE M FOGARTY MD PC
Entity Type:Organization
Organization Name:JACQUELINE M FOGARTY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-572-8300
Mailing Address - Street 1:409 OAK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1633
Mailing Address - Country:US
Mailing Address - Phone:434-572-8300
Mailing Address - Fax:434-572-1659
Practice Address - Street 1:409 OAK LN
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1633
Practice Address - Country:US
Practice Address - Phone:434-572-8300
Practice Address - Fax:434-572-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035912207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6401767Medicaid
VA200000704Medicare PIN