Basic Information
Provider Information | |||||||||
NPI: | 1578611588 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PATIENT FIRST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5000 COX RD | ||||||||
Address2: | ST 100 | ||||||||
City: | GLEN ALLEN | ||||||||
State: | VA | ||||||||
PostalCode: | 230609263 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12 N THOMPSON ST | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232212718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8043591337 | ||||||||
FaxNumber: | 8043589861 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEARSON | ||||||||
AuthorizedOfficialFirstName: | ANNE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DMS | ||||||||
AuthorizedOfficialTelephone: | 8043591337 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 0213000917 | VA | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
ID Information
ID | Type | State | Issuer | Description | NA | 05 | VA |   | MEDICAID | 4835318 | 01 |   | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |