Basic Information
| Provider Information | |||||||||
| NPI: | 1053340281 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACADEMIC PRIMARY CARE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 3708 S MAIN ST STE B | ||||||||
| Address2: | |||||||||
| City: | BLACKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240607007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407393623 | ||||||||
| FaxNumber: | 5407393979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 12/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | STULL | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5404437180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | VA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207V00000X | VA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208D00000X | VA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 204D00000X | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
ID Information
| ID | Type | State | Issuer | Description | 1053340281 | 05 | VA | MEDICAID | DG6086 | 01 | VA | RAILROAD MEDICARE | OTHER |