Provider Demographics
NPI:1164268165
Name:OLDE TOWNE MEDICAL PRACTICE PLLC
Entity type:Organization
Organization Name:OLDE TOWNE MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE BILLING CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-399-0701
Mailing Address - Street 1:301 GOODE WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2266
Mailing Address - Country:US
Mailing Address - Phone:757-399-0701
Mailing Address - Fax:757-399-3731
Practice Address - Street 1:301 GOODE WAY STE 103
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2266
Practice Address - Country:US
Practice Address - Phone:757-399-0701
Practice Address - Fax:757-399-3731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty