Provider Demographics
NPI:1134153448
Name:GREAT BRIDGE CHIROPRACTIC PHYSICIAN PC
Entity type:Organization
Organization Name:GREAT BRIDGE CHIROPRACTIC PHYSICIAN PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:MACDOWALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-549-2273
Mailing Address - Street 1:676 KINGSBOROUGH SQ
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4954
Mailing Address - Country:US
Mailing Address - Phone:757-549-2273
Mailing Address - Fax:757-548-1980
Practice Address - Street 1:676 KINGSBOROUGH SQ
Practice Address - Street 2:SUITE C
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4954
Practice Address - Country:US
Practice Address - Phone:757-549-2273
Practice Address - Fax:757-548-1980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001072111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU34281Medicare UPIN