Provider Demographics
NPI:1093750879
Name:GYN ONCOLOGY OF SOUTHWEST VIRGINIA LLC
Entity Type:Organization
Organization Name:GYN ONCOLOGY OF SOUTHWEST VIRGINIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-650-2907
Mailing Address - Street 1:1900 ELECTRIC RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7474
Mailing Address - Country:US
Mailing Address - Phone:540-776-4704
Mailing Address - Fax:540-769-2453
Practice Address - Street 1:1900 ELECTRIC RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7474
Practice Address - Country:US
Practice Address - Phone:540-776-4704
Practice Address - Fax:540-769-2453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1093750879Medicaid
WV3810000448Medicaid
VA1093750879Medicaid
VAC09075Medicare PIN