Provider Demographics
NPI:1093922726
Name:STONEWALL PEDIATRICS
Entity Type:Organization
Organization Name:STONEWALL PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN - PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-463-3162
Mailing Address - Street 1:108 HOUSTON ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-2455
Mailing Address - Country:US
Mailing Address - Phone:540-463-3162
Mailing Address - Fax:540-463-3213
Practice Address - Street 1:108 HOUSTON ST
Practice Address - Street 2:SUITE E
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-2455
Practice Address - Country:US
Practice Address - Phone:540-463-3162
Practice Address - Fax:540-463-3213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030878174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6737846Medicaid
VA1487706693OtherNPI FOR PHYSICIAN ASST.
VA1962587287OtherNPI
VA6737846Medicaid