Basic Information
Provider Information | |||||||||
NPI: | 1396734216 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LI | ||||||||
FirstName: | LI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9007 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTESVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 229069007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4342951000 | ||||||||
FaxNumber: | 4349724266 | ||||||||
Practice Location | |||||||||
Address1: | 1221 LEE STREET | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTESVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 229080001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4349245348 | ||||||||
FaxNumber: | 4349248335 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/14/2005 | ||||||||
LastUpdateDate: | 07/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101265674 | VA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2231669 | 05 | OH |   | MEDICAID | 363767 | 01 | OH | WELLCARE MEDICAID | OTHER | 2499012 | 01 | OH | AETNA | OTHER | 363766 | 01 | OH | WELLCARE | OTHER | 7545197 | 01 | OH | AETNA | OTHER | 000000213625 | 01 | OH | UNISON | OTHER | 737681 | 01 | OH | BUCKEYE | OTHER | 000000503553 | 01 | OH | ANTHEM | OTHER | 000000530392 | 01 | OH | ANTHEM | OTHER |