Basic Information
| Provider Information | |||||||||
| NPI: | 1780033050 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY | ||||||||
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| OtherOrganizationName: | VCU HEALTH NEUROSCIENCE,ORTHOPAEDIC AND WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 758997 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212758997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046286643 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11958 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | HENRICO | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232331007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046286643 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | DUVAL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8048280938 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H1875 | VA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00003 | 01 | VA | ANTHEM | OTHER |