Provider Demographics
NPI:1528641354
Name:TOWN SQUARE MEDICAL, PLLC
Entity type:Organization
Organization Name:TOWN SQUARE MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:L
Authorized Official - Last Name:JUSTUS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:276-783-1827
Mailing Address - Street 1:PO BOX 184
Mailing Address - Street 2:
Mailing Address - City:GLADE SPRING
Mailing Address - State:VA
Mailing Address - Zip Code:24340-0184
Mailing Address - Country:US
Mailing Address - Phone:276-783-1827
Mailing Address - Fax:276-783-2879
Practice Address - Street 1:202 TOWN SQUARE ST.
Practice Address - Street 2:
Practice Address - City:GLADE SPRING
Practice Address - State:VA
Practice Address - Zip Code:24340
Practice Address - Country:US
Practice Address - Phone:276-783-1827
Practice Address - Fax:276-783-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-29
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty