Provider Demographics
NPI:1730130667
Name:WINCHESTER INTERNAL MEDICINE, INC
Entity Type:Organization
Organization Name:WINCHESTER INTERNAL MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-662-6135
Mailing Address - Street 1:190 CAMPUS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2872
Mailing Address - Country:US
Mailing Address - Phone:540-662-6135
Mailing Address - Fax:540-662-5845
Practice Address - Street 1:190 CAMPUS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2872
Practice Address - Country:US
Practice Address - Phone:540-662-6135
Practice Address - Fax:540-662-5845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207R00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003817Medicaid
CB4305OtherRAILROAD MEDICARE GROUP
WV000875693OtherMTN STATE BS PAY VA GRP
MD550941600Medicare PIN
WV000875693OtherMTN STATE BS PAY VA GRP
WV3810003817Medicaid
WV9332051Medicare PIN
MD550941601Medicare PIN