Provider Demographics
NPI:1124112198
Name:CAPE CHARLES MEDICAL CENTER
Entity type:Organization
Organization Name:CAPE CHARLES MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-331-1422
Mailing Address - Street 1:216 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CHARLES
Mailing Address - State:VA
Mailing Address - Zip Code:23310-3200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 MASON AVE
Practice Address - Street 2:
Practice Address - City:CAPE CHARLES
Practice Address - State:VA
Practice Address - Zip Code:23310-3200
Practice Address - Country:US
Practice Address - Phone:757-331-1422
Practice Address - Fax:757-331-1624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA454260OtherANTHEM GROUP #
VAC08218OtherMEDICARE GROUP PTAN NUMBER
VA005642434Medicaid
VA005642451Medicaid
VACJ8918OtherGROUP#
VACJ8918OtherGROUP#
VAB05930Medicare UPIN