Provider Demographics
NPI:1780805622
Name:BLOCK, VIRGINIA
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:BLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 FURNACE BROOK RD
Mailing Address - Street 2:
Mailing Address - City:CORNWALL BRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06754-1124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 UPPER MAIN ST
Practice Address - Street 2:SUITE 7
Practice Address - City:SHARON
Practice Address - State:CT
Practice Address - Zip Code:06069-2083
Practice Address - Country:US
Practice Address - Phone:860-364-9840
Practice Address - Fax:860-364-1859
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002049174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY437135OtherMVP SPECIALIST
NYQC4921OtherEMPIRE BC BS
CT080002049 CT 03OtherANTHEM BC BS