Basic Information
| Provider Information | |||||||||
| NPI: | 1104093822 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRA HEALTH PROFESSIONAL SERVICES LLC | ||||||||
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| OtherOrganizationName: | LYNCHBURG INTERNAL MEDICINE A CENTRA HEALTH AFFILIATE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1204 FENWICK DR | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245022112 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1901 THOMSON DR | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245011008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342003908 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2008 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | TWEEDY | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4342005047 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRA HEALTH PROFESSIONAL SERVICES LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.