Provider Demographics
NPI:1194740084
Name:WOODSTOCK INTERNAL MEDICINE SPECIALISTS PC
Entity type:Organization
Organization Name:WOODSTOCK INTERNAL MEDICINE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GERMROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-459-1540
Mailing Address - Street 1:759 S MAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664-1127
Mailing Address - Country:US
Mailing Address - Phone:540-459-1540
Mailing Address - Fax:540-459-1486
Practice Address - Street 1:759 S MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1127
Practice Address - Country:US
Practice Address - Phone:540-459-1540
Practice Address - Fax:540-459-1486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC01152Medicare PIN