Basic Information
| Provider Information | |||||||||
| NPI: | 1033142708 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESTERFIELD OPHTHALMOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2385 COLONY CROSSING PL | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231124280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047392220 | ||||||||
| FaxNumber: | 8047392164 | ||||||||
| Practice Location | |||||||||
| Address1: | 2385 COLONY CROSSING PL | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231124280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047392220 | ||||||||
| FaxNumber: | 8047392164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | BUSCH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8047392220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 0102037038 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 006343295 | 05 | VA | MEDICAID |