Basic Information
Provider Information | |||||||||
NPI: | 1346356813 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RAPPAHANNOCK FAMILY HEALTHCARE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RAPPAHANNOCK FAMILY PHYSICIANS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 120 EXECUTIVE CENTER PKWY STE 215 | ||||||||
Address2: |   | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224013100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403745200 | ||||||||
FaxNumber: | 5403740378 | ||||||||
Practice Location | |||||||||
Address1: | 120 EXECUTIVE CENTER PKWY | ||||||||
Address2: |   | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224013100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403745200 | ||||||||
FaxNumber: | 5403730942 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2006 | ||||||||
LastUpdateDate: | 08/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
AuthorizedOfficialFirstName: | RAFAEL | ||||||||
AuthorizedOfficialMiddleName: | O. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5403745097 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 08/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0102036807 | VA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 5660599 | 05 | VA |   | MEDICAID |