Provider Demographics
NPI:1588903736
Name:MOBJACK MEDICAL GROUP
Entity type:Organization
Organization Name:MOBJACK MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:THORNTON
Authorized Official - Last Name:WEST
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:804-684-5043
Mailing Address - Street 1:6506 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-6103
Mailing Address - Country:US
Mailing Address - Phone:804-684-5043
Mailing Address - Fax:
Practice Address - Street 1:6506 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-6103
Practice Address - Country:US
Practice Address - Phone:804-684-5043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242319207R00000X
VA0101242168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty