Provider Demographics
NPI:1538292123
Name:PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC
Entity Type:Organization
Organization Name:PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC
Other - Org Name:MAIN STREET PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-925-1866
Mailing Address - Street 1:1033 28TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607-4233
Mailing Address - Country:US
Mailing Address - Phone:757-591-0643
Mailing Address - Fax:757-591-0682
Practice Address - Street 1:157 NORTH MAIN STREET SUITE A
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434
Practice Address - Country:US
Practice Address - Phone:757-925-1866
Practice Address - Fax:757-928-0906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7687648Medicaid
VA7687648Medicaid
VAC08408Medicare PIN