NPIMap

Organization Active NPI

Peninsula Institute for Community Health Inc

Doing business as Southeastern Virginia Health System at Western Tidewater Community Ser

  • Federally Qualified Health Center (FQHC)
  • Suffolk, VA
National Provider Identifier
1720462294
Registry record updated Jul 20, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC
Doing business as
Southeastern Virginia Health System at Western Tidewater Community Ser
Practice address
5268 Godwin Blvd
Suffolk, VA 23434-8114
Phone
(757) 255-7133
Fax
(757) 255-7142
NPI assigned
Jul 15, 2015
Last updated
Jul 20, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 20, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Angela Futrell
Title
Ceo
Phone
(757) 591-0643

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

5268 Godwin Blvd
Suffolk, VA 23434-8114

Mailing address

1033 28TH St
Newport News, VA 23607-4233
Phone (757) 591-0643

Other names 1

  • Southeastern Virginia Health System at Western Tidewater Community Ser Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040611000280 VA Part B Supplier - Clinic/Group Practice 9234040148 Receives reassigned benefits from 19 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Chesapeake, VA; Virginia Beach, VA; Suffolk, VA; Newport News, VA; Hampton, VA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1720462294. Details of each certification follow.

  • CCN 491942 Federally qualified health center · Active · Name & address match · Details

Federally qualified health center certification: CCN 491942

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
SOUTHEASTERN VA HLTH SYS AT WESTERN TIDEWATER COMM
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 29, 2015
Last certification
Oct 29, 2015
Ownership / control type
For profit – corporation
Facility address
5268 Godwin Boulevard
Suffolk, VA 23434

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1436918400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1437350400000",
    "number": "1720462294",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1033 28TH ST",
            "city": "NEWPORT NEWS",
            "state": "VA",
            "postal_code": "236074233",
            "telephone_number": "757-591-0643",
            "fax_number": "757-228-1045"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5268 GODWIN BLVD",
            "city": "SUFFOLK",
            "state": "VA",
            "postal_code": "234348114",
            "telephone_number": "757-255-7133",
            "fax_number": "757-255-7142"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-07-15",
        "last_updated": "2015-07-20",
        "status": "A",
        "authorized_official_last_name": "FUTRELL",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "757-591-0643"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southeastern Virginia Health System at Western Tidewater Community Ser",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Suffolk, VA

Sources for this page

Verify at the official NPI Registry.