Basic Information
| Provider Information | |||||||||
| NPI: | 1568699841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUDRICK | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71690 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232551690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042882830 | ||||||||
| FaxNumber: | 8042882850 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 MAPLE AVE | ||||||||
| Address2: | SUITE 200, NW MOB | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232262553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042852300 | ||||||||
| FaxNumber: | 8042858420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2009 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2014-00777 | NC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 0101258423 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1568699841 | 05 | VA | MEDICAID |