Provider Demographics
NPI:1689866691
Name:CHURCHLAND PODIATRY CENTER, PC
Entity Type:Organization
Organization Name:CHURCHLAND PODIATRY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-484-9535
Mailing Address - Street 1:108 AMERICAN LEGION RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5657
Mailing Address - Country:US
Mailing Address - Phone:757-484-9535
Mailing Address - Fax:757-484-9540
Practice Address - Street 1:108 AMERICAN LEGION RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5657
Practice Address - Country:US
Practice Address - Phone:757-484-9535
Practice Address - Fax:757-484-9540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000419213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA066587OtherANTHEM
VA0504920002Medicare NSC
VA066587OtherANTHEM