Provider Demographics
NPI:1245758135
Name:CROSSROADS TREATMENT CENTER OF SUFFOLK, PC
Entity Type:Organization
Organization Name:CROSSROADS TREATMENT CENTER OF SUFFOLK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUPERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMAC
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:800-805-6989
Mailing Address - Street 1:200 E BROAD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2891
Mailing Address - Country:US
Mailing Address - Phone:800-805-6989
Mailing Address - Fax:864-990-0653
Practice Address - Street 1:1258 HOLLAND RD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-6313
Practice Address - Country:US
Practice Address - Phone:757-809-4771
Practice Address - Fax:757-809-4932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-31
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251S00000X, 261QM2800X
261QM0801X, 261QM1300X, 261QP2300X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder