Provider Demographics
NPI:1366685018
Name:PIONEER HEALTH SERVICES OF PATRICK COUNTY, INC
Entity Type:Organization
Organization Name:PIONEER HEALTH SERVICES OF PATRICK COUNTY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:301 8TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-3967
Mailing Address - Country:US
Mailing Address - Phone:601-849-6440
Mailing Address - Fax:601-849-6443
Practice Address - Street 1:18688 JEB STUART HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171-1559
Practice Address - Country:US
Practice Address - Phone:276-694-8600
Practice Address - Fax:276-694-8679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1919207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA362626OtherBCBS ER
VA1982858585Medicaid