Basic Information
| Provider Information | |||||||||
| NPI: | 1578510780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRILLAMAN | ||||||||
| FirstName: | PRESCOTT | ||||||||
| MiddleName: | WADE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7611 FOREST AVE | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232294946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046738791 | ||||||||
| FaxNumber: | 8046733226 | ||||||||
| Practice Location | |||||||||
| Address1: | 7611 FOREST AVE | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232294946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046738791 | ||||||||
| FaxNumber: | 8046733226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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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 | 207V00000X | 0101056025 | VA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 006201849 | 05 | VA | MEDICAID | 160050950 | 01 | MEDICARE RR | OTHER | 1578510780 | 05 | VA | MEDICAID | 217097 | 01 | VA | ANTHEM | OTHER |