Basic Information
Provider Information | |||||||||
NPI: | 1184797789 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL VIRGINIA FAMILY PHYSICIANS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PIEDMONT FAMILY PRACTICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2489 | ||||||||
Address2: |   | ||||||||
City: | FOREST | ||||||||
State: | VA | ||||||||
PostalCode: | 245516489 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4343821125 | ||||||||
FaxNumber: | 4345255748 | ||||||||
Practice Location | |||||||||
Address1: | 2091 LANGHORNE RD | ||||||||
Address2: |   | ||||||||
City: | LYNCHBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 245011443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4348467374 | ||||||||
FaxNumber: | 4348461910 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2006 | ||||||||
LastUpdateDate: | 04/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OKIN | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4348467374 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CENTRAL VIRGINIA FAMILY PHYSICIANS, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | CF1947 | 01 | VA | MEDICARE RAILROAD | OTHER | 1528155892 | 05 | VA |   | MEDICAID | CC2392 | 01 | VA | MEDICARE RAILROAD | OTHER | 0907130008 | 01 | VA | DMEPOS | OTHER |