Provider Demographics
NPI:1972772929
Name:SUGAR HOLLOW MEDICAL
Entity type:Organization
Organization Name:SUGAR HOLLOW MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:GULDSETH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-466-3777
Mailing Address - Street 1:3177 LINDEN DR
Mailing Address - Street 2:SUITE #6
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-5812
Mailing Address - Country:US
Mailing Address - Phone:276-466-3777
Mailing Address - Fax:276-466-3705
Practice Address - Street 1:3177 LINDEN DR
Practice Address - Street 2:SUITE #6
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-5812
Practice Address - Country:US
Practice Address - Phone:276-466-3777
Practice Address - Fax:276-466-3705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231449207Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4053485OtherBLUE CROSS -- TN
VA5629934Medicaid
VA246144OtherBLUE CROSS--VA
VA00V083S29OtherMEDICARE
VA5629934Medicaid
VAC08529Medicare PIN