Basic Information
| Provider Information | |||||||||
| NPI: | 1720175953 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL VIRGINIA FAMILY PHYSICIANS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | STAUNTON RIVER FAMILY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2489 | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245516489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343821139 | ||||||||
| FaxNumber: | 4345255748 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 POCKET RD | ||||||||
| Address2: | |||||||||
| City: | HURT | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245632023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343249150 | ||||||||
| FaxNumber: | 4343248248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 05/16/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAYNES | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | STAFF CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4343821139 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRAL VIRGINIA FAMILY PHYSICIANS, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1528155892 | 05 | VA | MEDICAID | C03658 | 01 | VA | CVFP MCARE GROUP PTAN | OTHER | CC2392 | 01 | VA | MEDICARE RAILROAD | OTHER | 1528155892 | 01 | VA | CVFP CORPORATE NPI | OTHER |