Basic Information
| Provider Information | |||||||||
| NPI: | 1922311265 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIRGINIA INPATIENT MEDICINE ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 96368 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731436368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784418500 | ||||||||
| FaxNumber: | 6783970065 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE C-350 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784418500 | ||||||||
| FaxNumber: | 6783970065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2010 | ||||||||
| LastUpdateDate: | 07/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | TALBOT | ||||||||
| AuthorizedOfficialMiddleName: | GREEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT-CHIEF OPERATING OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 6784418500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAGLE HOSPITAL PHYSICIANS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5922470 | 05 | NC | MEDICAID | DR2432 | 01 | VA | RR MEDICARE | OTHER |