Basic Information
Provider Information
NPI: 1225110737
EntityType: 2
ReplacementNPI:  
OrganizationName: CENTRAL VIRGINIA FAMILY PHYSICIANS INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: CVFP AMELON IMMEDIATE CARE
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: 4343821139
FaxNumber: 4345255748
Practice Location
Address1: 200 AMELON SQ
Address2:  
City: MADISON HEIGHTS
State: VA
PostalCode: 245725981
CountryCode: US
TelephoneNumber: 4349291095
FaxNumber: 4349291098
Other Information
ProviderEnumerationDate: 10/20/2006
LastUpdateDate: 06/19/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: HAYNES
AuthorizedOfficialFirstName: KAREN
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: STAFF CREDENTIALING MANAGER
AuthorizedOfficialTelephone: 4343821139
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: CENTRAL VIRGINIA FAMILY PHYSICIANS, INC
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
122511073701VAFACILITY CLOSED 06/14/2014OTHER
CO365801VACVFP MCARE GROUP PTANOTHER
152815589201VACVFP CORPORATE NPIOTHER
152815589205VA MEDICAID
CA243601VAMEDICARE RAILROADOTHER


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