Provider Demographics
NPI:1114174653
Name:WINDSOR MEDICINE, PLLC
Entity Type:Organization
Organization Name:WINDSOR MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-430-8712
Mailing Address - Street 1:2601 SPRINGHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-3995
Mailing Address - Country:US
Mailing Address - Phone:757-430-8712
Mailing Address - Fax:
Practice Address - Street 1:70 E WINDSOR BLVD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VA
Practice Address - Zip Code:23487-9443
Practice Address - Country:US
Practice Address - Phone:757-430-8712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232665261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care