Basic Information
| Provider Information | |||||||||
| NPI: | 1043234552 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY RUN FAMILY MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5645 STONE RD | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201201618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032662442 | ||||||||
| FaxNumber: | 7032667158 | ||||||||
| Practice Location | |||||||||
| Address1: | 5645 STONE RD | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201201618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032662442 | ||||||||
| FaxNumber: | 7032667158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 09/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | MARKIN | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | SUSAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7032662442 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 144870 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 383306 | 01 | VA | ANTHEM BC/BS | OTHER | 5615691 | 05 | VA | MEDICAID | 8094-0001 | 01 | VA | CAREFIRST | OTHER | 5615712 | 05 | VA | MEDICAID | 8094-0004 | 01 | VA | CAREFIRST | OTHER | 383307 | 01 | VA | ANTHEM BC/BS | OTHER | 8094-0002 | 01 | VA | CAREFIRST | OTHER | 383308 | 01 | VA | ANTHEM BC/BS | OTHER | 5615747 | 05 | VA | MEDICAID |