Basic Information
| Provider Information | |||||||||
| NPI: | 1619976826 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRIVASTAVA | ||||||||
| FirstName: | PRAVEER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13000 RIVERS BEND BLVD | ||||||||
| Address2: | STE D | ||||||||
| City: | CHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238368632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045715106 | ||||||||
| FaxNumber: | 8045301857 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 CHARLES H DIMMOCK PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238342986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045265888 | ||||||||
| FaxNumber: | 8045265401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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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 | 0101231604 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 0101231604 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 006408613 | 05 | VA | MEDICAID | 200043080 | 01 | VA | RAILROAD MEDICARE | OTHER |