Basic Information
| Provider Information | |||||||||
| NPI: | 1548821630 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VCU HEALTH ORTHOPEDICS AT SOUTH PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 758997 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212750001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046286643 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 325 CHARLES H DIMMOCK PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238342986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045265888 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2019 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | HANCOCK | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
| AuthorizedOfficialMiddleName: | SUMMERLIN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8046283343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000003 | 01 | VA | ANTHEM | OTHER |