Basic Information
Provider Information | |||||||||
NPI: | 1508825241 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TUCKER CARDIOLOGY ASSOCIATES PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11768 | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232300168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8045456866 | ||||||||
FaxNumber: | 8042139783 | ||||||||
Practice Location | |||||||||
Address1: | 8401 N RUN MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | MECHANICSVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 231162309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8045599902 | ||||||||
FaxNumber: | 8045599904 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TUCKER | ||||||||
AuthorizedOfficialFirstName: | STANLEY | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
AuthorizedOfficialTelephone: | 8045599903 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 005812836 | 05 | VA |   | MEDICAID |