Provider Demographics
NPI:1275637241
Name:NORTON COMMUNITY PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:NORTON COMMUNITY PHYSICIAN SERVICES LLC
Other - Org Name:BALLAD HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5185
Mailing Address - Street 1:311 PRINCETON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2080
Mailing Address - Country:US
Mailing Address - Phone:276-439-1360
Mailing Address - Fax:276-439-1305
Practice Address - Street 1:1490 PARK AVE NW STE 7
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1631
Practice Address - Country:US
Practice Address - Phone:276-439-1360
Practice Address - Fax:276-439-1305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010027453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2104972OtherPK
VA8520062Medicaid
VA8520062Medicaid