Basic Information
| Provider Information | |||||||||
| NPI: | 1528155892 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL VIRGINIA FAMILY PHYSICIANS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CENTRAL VIRGINIA FAMILY PHYSICIANS, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1111 CORPORATE PARK DR | ||||||||
| Address2: | STE C | ||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245512286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343821139 | ||||||||
| FaxNumber: | 4345255748 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 CORPORATE PARK DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245512286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343821139 | ||||||||
| FaxNumber: | 4345255748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRAWFORD | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4343821139 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1528155892 | 05 | VA | MEDICAID | CA2436 | 01 | VA | MEDICARE RAILROAD CARRIER | OTHER | CF1947 | 01 | VA | MEDICARE RAILROAD CARRIER | OTHER | CI3834 | 01 | VA | MEDICARE RAILROAD CARRIER | OTHER | CC2392 | 01 | VA | MEDICARE RAILROAD CARRIER | OTHER |