Provider Demographics
NPI:1881847135
Name:EASTERN SHORE RURAL HEALTH SYSTEM INCORPORATED
Entity Type:Organization
Organization Name:EASTERN SHORE RURAL HEALTH SYSTEM INCORPORATED
Other - Org Name:PUNGOTEAGUE ELEMENTARY SCHOOL DENTAL PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-414-0400
Mailing Address - Street 1:20280 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ONANCOCK
Mailing Address - State:VA
Mailing Address - Zip Code:23417-1331
Mailing Address - Country:US
Mailing Address - Phone:757-414-0400
Mailing Address - Fax:757-414-0569
Practice Address - Street 1:28480 BOBTOWN RD
Practice Address - Street 2:
Practice Address - City:MELFA
Practice Address - State:VA
Practice Address - Zip Code:23410-3508
Practice Address - Country:US
Practice Address - Phone:757-789-7777
Practice Address - Fax:757-789-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008450552Medicaid