Basic Information
Provider Information | |||||||||
NPI: | 1194040766 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RICHMOND MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PATIENT FIRST FREDERICKSBURG | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3031 PLANK RD | ||||||||
Address2: |   | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224014951 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407365043 | ||||||||
FaxNumber: | 5407365044 | ||||||||
Practice Location | |||||||||
Address1: | 3031 PLANK RD | ||||||||
Address2: |   | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224014951 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407365043 | ||||||||
FaxNumber: | 5407365044 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2010 | ||||||||
LastUpdateDate: | 01/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRIDGERS | ||||||||
AuthorizedOfficialFirstName: | MARVIN | ||||||||
AuthorizedOfficialMiddleName: | WARREN | ||||||||
AuthorizedOfficialTitleorPosition: | DIR. OF PHARMACY | ||||||||
AuthorizedOfficialTelephone: | 8048224383 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: | RPH | ||||||||
NPICertificationDate: | 01/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 213000653 | VA | N |   | Suppliers | Non-Pharmacy Dispensing Site |   | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.