Basic Information
| Provider Information | |||||||||
| NPI: | 1396826046 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOMINION MEDICAL ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5449 | ||||||||
| Address2: | 304 EAST LEIGH STREET | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232200449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042257148 | ||||||||
| FaxNumber: | 8042257159 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 E LEIGH ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232191410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042257148 | ||||||||
| FaxNumber: | 8042257159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 05/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESEND | ||||||||
| AuthorizedOfficialTelephone: | 8042257148 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1396826046 | 01 | VA | NPI GROUP NUMBER | OTHER |