Provider Demographics
NPI:1881700946
Name:SOUTHAMPTON PRIMARY CARE
Entity type:Organization
Organization Name:SOUTHAMPTON PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ITRISH
Authorized Official - Middle Name:JOUBY
Authorized Official - Last Name:SCOTT-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-562-1421
Mailing Address - Street 1:P.O. BOX 26
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851
Mailing Address - Country:US
Mailing Address - Phone:757-562-1421
Mailing Address - Fax:757-562-1423
Practice Address - Street 1:102 FAIRVIEW DR
Practice Address - Street 2:SUITE F
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851
Practice Address - Country:US
Practice Address - Phone:757-562-1421
Practice Address - Fax:757-562-1423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010029261Medicaid
VA010029261Medicaid