Basic Information
| Provider Information | |||||||||
| NPI: | 1932685526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRA MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | CMG ANESTHESIA SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1937 THOMSON DR | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245011008 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 RIVERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245032030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342005047 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2018 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | LARKIN | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PAYER CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4342005047 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRA MEDICAL GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.