Basic Information
| Provider Information | |||||||||
| NPI: | 1447251707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEELY | ||||||||
| FirstName: | GEORGIA | ||||||||
| MiddleName: | KANNON | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KANNON | ||||||||
| OtherFirstName: | GEORGIA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 CONCOURSE BLVD STE 190 | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230595759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045494030 | ||||||||
| FaxNumber: | 8045494032 | ||||||||
| Practice Location | |||||||||
| Address1: | 10710 MIDLOTHIAN TURNPIKE | ||||||||
| Address2: | STE 401 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047942307 | ||||||||
| FaxNumber: | 8047942944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 10/19/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 0101048279 | VA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 785171 | 01 | AETNA | OTHER | 070010579 | 01 | RAILROAD MEDICARE | OTHER | 147157 | 01 | SOUTHERN HEALTH | OTHER | 107147 | 01 | ANTHEM | OTHER | 0300119 | 01 | UNITED HEALTHCARE | OTHER | 5900921 | 05 | VA | MEDICAID |