Provider Demographics
NPI:1750417937
Name:STEPHEN MADDOCK MD PHD PLC
Entity type:Organization
Organization Name:STEPHEN MADDOCK MD PHD PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-242-9191
Mailing Address - Street 1:70 E WINDSOR BLVD
Mailing Address - Street 2:STE G
Mailing Address - City:WINDSOR
Mailing Address - State:VA
Mailing Address - Zip Code:23487-9443
Mailing Address - Country:US
Mailing Address - Phone:757-242-9191
Mailing Address - Fax:757-242-9922
Practice Address - Street 1:70 E WINDSOR BLVD
Practice Address - Street 2:STE G
Practice Address - City:WINDSOR
Practice Address - State:VA
Practice Address - Zip Code:23487-9443
Practice Address - Country:US
Practice Address - Phone:757-242-9191
Practice Address - Fax:757-242-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-24
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA5937Medicare PIN
C08637Medicare PIN