Active NPI
Wendell T Poulsen Jr., M.D.
- Family Medicine Physician
- Gloucester, VA
National Provider Identifier
1457326811
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 0101031371
- Practice address
- 5659 Parkway Dr
Ste 100
Gloucester, VA 23061-3792 - Phone
- (804) 210-1005
- Fax
- (804) 210-1009
- NPI assigned
- Feb 21, 2006
- Last updated
- Jan 11, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 0101031371 | VA | Primary |
Addresses
Primary practice location
5659 Parkway Dr
Ste 100
Gloucester, VA 23061-3792
Mailing address
5659 Parkway Dr
Ste 100
Gloucester, VA 23061-3792
Phone (804) 210-1005
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 010156041 | Medicaid | VA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mary Immaculate Hospital LLC | Past | Accepting new patients |
Interoperability endpoints
- wendell.poulsen.1@16026.direct.athenahealth.com
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
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NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1140480000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1326240000000",
"number": "1457326811",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5659 PARKWAY DR",
"address_2": "STE 100",
"city": "GLOUCESTER",
"state": "VA",
"postal_code": "230613792",
"telephone_number": "804-210-1005",
"fax_number": "804-210-1009"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5659 PARKWAY DR",
"address_2": "STE 100",
"city": "GLOUCESTER",
"state": "VA",
"postal_code": "230613792",
"telephone_number": "804-210-1005",
"fax_number": "804-210-1009"
}
],
"practiceLocations": [],
"basic": {
"last_name": "POULSEN",
"first_name": "WENDELL",
"middle_name": "T",
"name_prefix": "Dr.",
"name_suffix": "Jr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-02-21",
"last_updated": "2012-01-11",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "VA",
"license": "0101031371",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "010156041",
"state": "VA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Gloucester, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 11, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.