VERNON J HARRIS EAST END COMMUNITY HEALTH CENTER (GLENWOOD MEDICAL CENTER) - NPI NUMBER 1396078135

Summary

Provider Name: VERNON J HARRIS EAST END COMMUNITY HEALTH CENTER (GLENWOOD MEDICAL CENTER)

NPI Number: 1396078135

Clasification: Clinic/Center (261QF0400X)

Specialization: Federally Qualified Health Center (FQHC)

Address:
2711 BYRON ST
RICHMOND, VA
ZIP 23223

Phone Number: (804) 525-1818



Detailed Information

VERNON J HARRIS EAST END COMMUNITY HEALTH CENTER is a federally qualified health center (fqhc) clinic/center in Richmond, VA. The assigned NPI number for this provider is 1396078135 and is registered as an organization entity type.
The provider Is Doing Business As Glenwood Medical Center.

The provider's business address is:

2711 BYRON ST
RICHMOND, VA
ZIP 23223-313
Phone: (804) 525-1818
Fax: (804) 525-1820

The provider's authorized official is Tracy Causey .
The authorized official title is Executive Director and has the following contact phone number (804) 591-2890.

The enumeration date for this NPI number is 9/11/2009 and was last updated on 12/4/2012.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 261QF0400X Clinic/Center Federally Qualified Health Center (FQHC) Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 C06017 MEDICARE PIN VA
2 1396078135 MEDICAID VA
3 491900 MEDICARE OSCAR/CERTIFICATION VA

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1396078135 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name VERNON J HARRIS EAST END COMMUNITY HEALTH CENTER The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider Other Organization Name GLENWOOD MEDICAL CENTER Other name by which the organization provider is or has been known.
6 Provider Other Organization Name Type Code 3 Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
7 Provider First Line Business Practice Location Address 2711 BYRON ST The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
8 Provider Business Practice Location Address City Name RICHMOND The city name in the location address of the provider being identified.
9 Provider Business Practice Location Address State Name VA The State code in the location of the provider being identified.
10 Provider Business Practice Location Address Postal Code 232231313 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
11 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
12 Provider Business Practice Location Address Telephone Number 8045251818 The telephone number associated with the location address of the provider being identified.
13 Provider Business Practice Location Address Fax Number 8045251820 The fax number associated with the location address of the provider being identified.
14 Provider Enumeration Date 9/11/2009 The date the provider was assigned a unique identifier (assigned an NPI).
15 Last Update Date 12/4/2012 The date that a record was last updated or changed.
16 Authorized Official Last Name CAUSEY The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
17 Authorized Official First Name TRACY The first name of the authorized official.
18 Authorized Official Title or Position EXECUTIVE DIRECTOR The title or position of the authorized official.
19 Authorized Official Telephone Number 8045912890 The 10-position telephone number of the authorized official.
20 Healthcare Provider Taxonomy Code 1 261QF0400X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
21 Healthcare Provider Primary Taxonomy Switch 1 Y
22 Other Provider Identifier 1 C06017 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
23 Other Provider Identifier Type Code 1 08 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
24 Other Provider Identifier State 1 VA
25 Other Provider Identifier 2 1396078135 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
26 Other Provider Identifier Type Code 2 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
27 Other Provider Identifier State 2 VA
28 Other Provider Identifier 3 491900 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
29 Other Provider Identifier Type Code 3 06 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
30 Other Provider Identifier State 3 VA
31 Is Organization Subpart N

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This page was last updated on: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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